Provider Demographics
NPI:1568905495
Name:KIKAM, KISITO N
Entity Type:Individual
Prefix:DR
First Name:KISITO
Middle Name:N
Last Name:KIKAM
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 1:1500 W KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4009
Mailing Address - Country:US
Mailing Address - Phone:870-240-8053
Mailing Address - Fax:
Practice Address - Street 1:108 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5940
Practice Address - Country:US
Practice Address - Phone:870-802-3749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-26
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12515183500000X
OH03-2-33562183500000X
NC24001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist