Provider Demographics
NPI:1942582291
Name:KRUCKMAN, MALLORY (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:KRUCKMAN
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9724 TIMBERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3507
Mailing Address - Country:US
Mailing Address - Phone:847-691-1727
Mailing Address - Fax:
Practice Address - Street 1:2811 HOLMANS LN
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-5915
Practice Address - Country:US
Practice Address - Phone:812-288-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023808A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist