Provider Demographics
NPI:1184874711
Name:WALICKE, PAUL ANTHONY (RPH)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:WALICKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 PALOMINO LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-5458
Mailing Address - Country:US
Mailing Address - Phone:859-523-5475
Mailing Address - Fax:
Practice Address - Street 1:851 IRELAND AVE
Practice Address - Street 2:IRELAND ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-2722
Practice Address - Country:US
Practice Address - Phone:502-624-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist