Provider Demographics
NPI:1619005758
Name:FORTNER, ELAINE (RPH)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:FORTNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 62
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-9504
Mailing Address - Country:US
Mailing Address - Phone:812-387-4006
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 227
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-9738
Practice Address - Country:US
Practice Address - Phone:812-387-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016068A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist