Basic Information
| Provider Information | |||||||||
| NPI: | 1972103786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALK | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ECKERLE | ||||||||
| OtherFirstName: | JAN | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5868 W RILLA MAE RD | ||||||||
| Address2: | |||||||||
| City: | TASWELL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471757123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126130629 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 735 N GOSPEL ST | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474541419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127233944 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 26017238A | IN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.