Healthcare Provider Details

I. General information

NPI: 1598991804
Provider Name (Legal Business Name): KEVIN LANCE KIRBY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E MAIN ST
LAKE BUTLER FL
32054-1352
US

IV. Provider business mailing address

625 E MAIN ST
LAKE BUTLER FL
32054-1352
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-8099
  • Fax: 386-496-3796
Mailing address:
  • Phone: 386-496-8099
  • Fax: 386-496-3796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS32658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: