Provider Demographics
NPI:1013291806
Name:KETTMANN, INGRID MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:MARIE
Last Name:KETTMANN
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 1:4400 LEMAY FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1758
Mailing Address - Country:US
Mailing Address - Phone:314-487-0636
Mailing Address - Fax:314-487-8819
Practice Address - Street 1:4400 LEMAY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1758
Practice Address - Country:US
Practice Address - Phone:314-487-0636
Practice Address - Fax:314-487-8819
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006026109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist