Provider Demographics
NPI:1801134374
Name:IKETANI, KURT M (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:M
Last Name:IKETANI
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 E SILVER SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-6406
Mailing Address - Country:US
Mailing Address - Phone:352-671-3770
Mailing Address - Fax:352-671-3771
Practice Address - Street 1:3450 E SILVER SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6406
Practice Address - Country:US
Practice Address - Phone:352-671-3770
Practice Address - Fax:352-671-3771
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist