Provider Demographics
NPI:1508225681
Name:DIETRICH, KATHLEEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-8441
Mailing Address - Country:US
Mailing Address - Phone:859-898-1620
Mailing Address - Fax:859-448-1221
Practice Address - Street 1:1700 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-8441
Practice Address - Country:US
Practice Address - Phone:859-898-1620
Practice Address - Fax:859-448-1221
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03232646-2183500000X, 1835P0018X
KY016456183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist