Provider Demographics
NPI:1205007085
Name:ICKES, KIMBERLY L (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:L
Last Name:ICKES
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 1:608 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-1102
Mailing Address - Country:US
Mailing Address - Phone:440-963-2260
Mailing Address - Fax:
Practice Address - Street 1:1605 STATE ROUTE 60
Practice Address - Street 2:SUITE 11
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089
Practice Address - Country:US
Practice Address - Phone:440-967-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-10057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist