Provider Demographics
NPI:1295335339
Name:PEACOCK, KATHERINE DENISE (PHARMD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DENISE
Last Name:PEACOCK
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 1:5819 RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2729
Mailing Address - Country:US
Mailing Address - Phone:574-540-9129
Mailing Address - Fax:
Practice Address - Street 1:4837 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-3533
Practice Address - Country:US
Practice Address - Phone:317-830-4259
Practice Address - Fax:317-830-4103
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026634A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist