Provider Demographics
NPI:1083951685
Name:DIMICCO, KRISTINA (RPH)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:
Last Name:DIMICCO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 21ST ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5455
Mailing Address - Country:US
Mailing Address - Phone:772-562-0541
Mailing Address - Fax:772-562-0789
Practice Address - Street 1:415 21ST ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5455
Practice Address - Country:US
Practice Address - Phone:772-562-0541
Practice Address - Fax:772-562-0789
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist