Provider Demographics
NPI:1861039646
Name:FELTON, CARLISSA
Entity Type:Individual
Prefix:
First Name:CARLISSA
Middle Name:
Last Name:FELTON
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 1:180 CINDY LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-8215
Mailing Address - Country:US
Mailing Address - Phone:765-576-0013
Mailing Address - Fax:
Practice Address - Street 1:500 S LIBERTY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-1924
Practice Address - Country:US
Practice Address - Phone:812-349-1391
Practice Address - Fax:812-349-1393
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026132A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist