Provider Demographics
NPI:1861870552
Name:SPONSEL, KEVIN JOSEPH (PHARMD, BCPS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:SPONSEL
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11712 STEAMBOAT DR APT 2312
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-6522
Mailing Address - Country:US
Mailing Address - Phone:402-596-5754
Mailing Address - Fax:
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-8892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE142441835P0018X
IN26025528A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE14244OtherPHARMACIST LICENSE NUMBER
IN26025528AOtherPHARMACIST LICENSE NUMBER
DC3141393FOtherBOARD OF PHARMACEUTICAL SPECIALTIES CERTIFICATION NUMBER