Provider Demographics
NPI:1780280891
Name:THACKERY, KATIE ANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ANNE
Last Name:THACKERY
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 1:31 METAMORA RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47012-1437
Mailing Address - Country:US
Mailing Address - Phone:765-647-3533
Mailing Address - Fax:
Practice Address - Street 1:31 METAMORA RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47012-1437
Practice Address - Country:US
Practice Address - Phone:765-647-3533
Practice Address - Fax:765-647-0673
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023054A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist