Provider Demographics
NPI:1497361208
Name:HETTINGER, KERRY
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:HETTINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 SCHILLER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1946
Mailing Address - Country:US
Mailing Address - Phone:502-322-5609
Mailing Address - Fax:
Practice Address - Street 1:1114 SCHILLER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1946
Practice Address - Country:US
Practice Address - Phone:502-322-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0195133336C0003X
IN26027404A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy