Provider Demographics
NPI:1700326774
Name:HEAD, KATIE PETERICH
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:PETERICH
Last Name:HEAD
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 1:349 E BLUEBIRD RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-6744
Mailing Address - Country:US
Mailing Address - Phone:863-207-8664
Mailing Address - Fax:
Practice Address - Street 1:349 E BLUEBIRD RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-6744
Practice Address - Country:US
Practice Address - Phone:863-207-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist