Provider Demographics
NPI:1518693647
Name:WATERMAN, LACEY ANNETTE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:ANNETTE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 PIN OAK CIR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-3276
Mailing Address - Country:US
Mailing Address - Phone:785-248-1877
Mailing Address - Fax:
Practice Address - Street 1:6829 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-6083
Practice Address - Country:US
Practice Address - Phone:785-228-4204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-106948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist