Provider Demographics
NPI:1164998647
Name:MCKIVER, TIARA ALEXIS
Entity Type:Individual
Prefix:DR
First Name:TIARA
Middle Name:ALEXIS
Last Name:MCKIVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 ARBOR LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-7369
Mailing Address - Country:US
Mailing Address - Phone:407-321-0880
Mailing Address - Fax:
Practice Address - Street 1:10601 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-7237
Practice Address - Country:US
Practice Address - Phone:352-365-6817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS58289OtherPHARMACY LICENSE