Provider Demographics
NPI:1154804714
Name:PINE, PATRICIA LYNNE (RPH)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNNE
Last Name:PINE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47841-1332
Mailing Address - Country:US
Mailing Address - Phone:812-939-2173
Mailing Address - Fax:812-939-2508
Practice Address - Street 1:730 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:IN
Practice Address - Zip Code:47841-1332
Practice Address - Country:US
Practice Address - Phone:812-939-2173
Practice Address - Fax:812-939-2508
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019497A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26019497AOtherINDIANA BOARD OF PHARMACY