Healthcare Provider Details

I. General information

NPI: 1952875684
Provider Name (Legal Business Name): KARISA WILKS ZICKOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3782 OLD US 41 N
VALDOSTA GA
31602-6834
US

IV. Provider business mailing address

3782 OLD US 41 N
VALDOSTA GA
31602-6834
US

V. Phone/Fax

Practice location:
  • Phone: 229-253-0067
  • Fax:
Mailing address:
  • Phone: 229-253-0067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14396
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: