Provider Demographics
NPI:1013516079
Name:KING, RICKY JAMES
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:JAMES
Last Name:KING
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 1:1494 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-9493
Mailing Address - Country:US
Mailing Address - Phone:812-865-3266
Mailing Address - Fax:
Practice Address - Street 1:1494 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-9493
Practice Address - Country:US
Practice Address - Phone:812-865-3266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014528A1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care