Provider Demographics
NPI:1790386290
Name:LUCKFIELD, KATIE ANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANNE
Last Name:LUCKFIELD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANNE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MO
Mailing Address - Zip Code:65753-0638
Mailing Address - Country:US
Mailing Address - Phone:417-813-5077
Mailing Address - Fax:
Practice Address - Street 1:916 SPRINGFIELD RD STE F
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608-5477
Practice Address - Country:US
Practice Address - Phone:417-683-9550
Practice Address - Fax:417-250-8002
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015022712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist