Basic Information
Provider Information | |||||||||
NPI: | 1295047264 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEHAULT | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOLAN | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | MARY | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4 W LAKE RD | ||||||||
Address2: |   | ||||||||
City: | WARWICK | ||||||||
State: | NY | ||||||||
PostalCode: | 109902605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144759458 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 900 WASHINGTON RD | ||||||||
Address2: |   | ||||||||
City: | WEST POINT | ||||||||
State: | NY | ||||||||
PostalCode: | 109961109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8459382271 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2010 | ||||||||
LastUpdateDate: | 01/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 63238 | CA | Y |   | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 183500000X | 63238 | CA | N |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.