Provider Demographics
NPI:1992345839
Name:KOENEMANN, EMILY JANE (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:JANE
Last Name:KOENEMANN
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 1:7430 CLINGMANS TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1418
Mailing Address - Country:US
Mailing Address - Phone:269-929-8111
Mailing Address - Fax:
Practice Address - Street 1:1350 S RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:GARRETT
Practice Address - State:IN
Practice Address - Zip Code:46738-1971
Practice Address - Country:US
Practice Address - Phone:260-553-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034007183500000X
IN26022154A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist