Provider Demographics
NPI:1790122109
Name:ILTIS, KATHERINE E (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:E
Last Name:ILTIS
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 1:6910 HART LN
Mailing Address - Street 2:#803
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4150
Mailing Address - Country:US
Mailing Address - Phone:210-355-2956
Mailing Address - Fax:
Practice Address - Street 1:2525 W ANDERSON LN
Practice Address - Street 2:BLDG 2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1180
Practice Address - Country:US
Practice Address - Phone:210-355-2956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist