Provider Demographics
NPI:1043622061
Name:DIVERS, KALE ALEXANDER
Entity Type:Individual
Prefix:MR
First Name:KALE
Middle Name:ALEXANDER
Last Name:DIVERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 MILAN RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-8911
Mailing Address - Country:US
Mailing Address - Phone:419-627-7933
Mailing Address - Fax:419-627-7965
Practice Address - Street 1:4702 MILAN RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-8911
Practice Address - Country:US
Practice Address - Phone:419-627-7933
Practice Address - Fax:419-627-7965
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-25
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03136199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist