Provider Demographics
NPI:1821420837
Name:DOMER, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:DOMER
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 1:5189 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039
Mailing Address - Country:US
Mailing Address - Phone:315-699-0812
Mailing Address - Fax:
Practice Address - Street 1:6189 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8960
Practice Address - Country:US
Practice Address - Phone:315-699-0812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist