Provider Demographics
NPI:1275129405
Name:ICE, DEVIN RYAN
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:RYAN
Last Name:ICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7722 W STATE ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2529
Mailing Address - Country:US
Mailing Address - Phone:812-853-6166
Mailing Address - Fax:
Practice Address - Street 1:7722 W STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2529
Practice Address - Country:US
Practice Address - Phone:812-853-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026765A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist