Provider Demographics
NPI:1225368525
Name:KICKLITER, JUSTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:KICKLITER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-2323
Mailing Address - Country:US
Mailing Address - Phone:423-720-9777
Mailing Address - Fax:423-720-9778
Practice Address - Street 1:136 E BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-2323
Practice Address - Country:US
Practice Address - Phone:423-720-9777
Practice Address - Fax:423-720-9778
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000029500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist