Provider Demographics
NPI:1669822110
Name:DIECKMANN, KEVIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:DIECKMANN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 W SANILAC RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-9667
Mailing Address - Country:US
Mailing Address - Phone:810-648-4247
Mailing Address - Fax:
Practice Address - Street 1:655 W SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-9667
Practice Address - Country:US
Practice Address - Phone:810-648-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist