Provider Demographics
NPI:1356623037
Name:ETZLER, KAM ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:KAM
Middle Name:ELLEN
Last Name:ETZLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10170 MAYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9589
Mailing Address - Country:US
Mailing Address - Phone:260-486-7295
Mailing Address - Fax:260-486-9395
Practice Address - Street 1:10170 MAYSVILLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9589
Practice Address - Country:US
Practice Address - Phone:260-486-7295
Practice Address - Fax:260-486-9395
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019563A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist