Provider Demographics
NPI:1477240794
Name:STORCK, REBECCA (PHARMD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:STORCK
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 1:14406 BROAD OAK PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5135
Mailing Address - Country:US
Mailing Address - Phone:812-480-4473
Mailing Address - Fax:
Practice Address - Street 1:1250 PATROL RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-8670
Practice Address - Country:US
Practice Address - Phone:855-647-7379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY018861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist