Provider Demographics
NPI:1750725123
Name:EWELLLINDLEY, KIM DIANE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:DIANE
Last Name:EWELLLINDLEY
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 1:2620 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-3556
Mailing Address - Country:US
Mailing Address - Phone:765-668-0208
Mailing Address - Fax:
Practice Address - Street 1:2620 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-3556
Practice Address - Country:US
Practice Address - Phone:765-668-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024950A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26024950AOtherINDIANA BOARD OF PHARMACY