Provider Demographics
NPI:1154848547
Name:CICCHETTI, KATLIN MAY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATLIN
Middle Name:MAY
Last Name:CICCHETTI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KATLIN
Other - Middle Name:MAY
Other - Last Name:CORMIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:13198 N TELLURIDE LOOP
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-3308
Mailing Address - Country:US
Mailing Address - Phone:509-855-2351
Mailing Address - Fax:
Practice Address - Street 1:121 W NEIDER AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9300
Practice Address - Country:US
Practice Address - Phone:208-765-4410
Practice Address - Fax:208-765-0451
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60749814183500000X
IDP7950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist