Provider Demographics
NPI:1982200663
Name:KETCHMARK, LAUREN LEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:LEE
Last Name:KETCHMARK
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 1:10555 LEHIGH RD S
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-9155
Mailing Address - Country:US
Mailing Address - Phone:651-249-3074
Mailing Address - Fax:
Practice Address - Street 1:2001 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3924
Practice Address - Country:US
Practice Address - Phone:651-451-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist