Provider Demographics
NPI:1295127587
Name:KICKLIGHTER PETERMAN, JUNE
Entity type:Individual
Prefix:
First Name:JUNE
Middle Name:
Last Name:KICKLIGHTER PETERMAN
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 1:2435 GRANADA CIR E
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-3917
Mailing Address - Country:US
Mailing Address - Phone:727-480-7260
Mailing Address - Fax:
Practice Address - Street 1:2435 GRANADA CIR E
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-3917
Practice Address - Country:US
Practice Address - Phone:727-480-7260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0022118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist