Provider Demographics
NPI:1629671987
Name:IRELAND, KATIE LEANN (PHARM D)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LEANN
Last Name:IRELAND
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 E 1250 AVE
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-4044
Mailing Address - Country:US
Mailing Address - Phone:618-780-9256
Mailing Address - Fax:
Practice Address - Street 1:1401 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1028
Practice Address - Country:US
Practice Address - Phone:618-283-0196
Practice Address - Fax:618-283-9150
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist