Provider Demographics
NPI:1578207189
Name:KERTH, KALIE RENEE
Entity Type:Individual
Prefix:
First Name:KALIE
Middle Name:RENEE
Last Name:KERTH
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 1:1201 BIRCH
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-1000
Mailing Address - Country:US
Mailing Address - Phone:405-219-1172
Mailing Address - Fax:888-978-7603
Practice Address - Street 1:100 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-3001
Practice Address - Country:US
Practice Address - Phone:580-774-3043
Practice Address - Fax:888-978-7603
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist