Provider Demographics
NPI:1740631688
Name:CONDO, KATHLEEN (PHARMD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CONDO
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 1:4109 HONEY CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9155
Mailing Address - Country:US
Mailing Address - Phone:765-883-8086
Mailing Address - Fax:
Practice Address - Street 1:201 N DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4131
Practice Address - Country:US
Practice Address - Phone:765-457-1191
Practice Address - Fax:765-868-3184
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018620A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist