Healthcare Provider Details

I. General information

NPI: 1194027623
Provider Name (Legal Business Name): ANTHONY LEE KICKLIGHTER RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2010
Last Update Date: 12/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 PROFESSIONAL CIR STE B
SAINT MARYS GA
31558-3783
US

IV. Provider business mailing address

913 SEAGROVE ST
SAINT MARYS GA
31558-8516
US

V. Phone/Fax

Practice location:
  • Phone: 912-673-8220
  • Fax: 912-673-7035
Mailing address:
  • Phone: 912-673-8220
  • Fax: 912-673-7035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number018501
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: