Provider Demographics
NPI:1710592134
Name:DETTLINGER, CASEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:DETTLINGER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 STERLING RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3523
Mailing Address - Country:US
Mailing Address - Phone:502-599-0130
Mailing Address - Fax:
Practice Address - Street 1:11930 STANDIFORD PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-5901
Practice Address - Country:US
Practice Address - Phone:502-961-5843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028978A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist