Provider Demographics
NPI:1952875684
Name:ZICKOS, KARISA WILKS
Entity Type:Individual
Prefix:
First Name:KARISA
Middle Name:WILKS
Last Name:ZICKOS
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 1:3782 OLD US 41 N
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6834
Mailing Address - Country:US
Mailing Address - Phone:229-253-0067
Mailing Address - Fax:
Practice Address - Street 1:3782 OLD US 41 N
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6834
Practice Address - Country:US
Practice Address - Phone:229-253-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14396183500000X
GA25319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist