Provider Demographics
NPI:1790125375
Name:ENGALND, TABATHA M
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:M
Last Name:ENGALND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 ECHO RD
Mailing Address - Street 2:
Mailing Address - City:KNOB LICK
Mailing Address - State:KY
Mailing Address - Zip Code:42154-8341
Mailing Address - Country:US
Mailing Address - Phone:270-432-7574
Mailing Address - Fax:270-432-7750
Practice Address - Street 1:612 W STOCKTON ST
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129-9458
Practice Address - Country:US
Practice Address - Phone:270-432-3865
Practice Address - Fax:270-432-7750
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT00013046183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician