Provider Demographics
NPI:1467949883
Name:ICKES, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:ICKES
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 1:13215 SILVER THORN LOOP UNIT 208
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-8911
Mailing Address - Country:US
Mailing Address - Phone:419-651-0356
Mailing Address - Fax:
Practice Address - Street 1:12041 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-4807
Practice Address - Country:US
Practice Address - Phone:239-693-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist