Healthcare Provider Details

I. General information

NPI: 1275129405
Provider Name (Legal Business Name): DEVIN RYAN ICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7722 W STATE ROUTE 66
NEWBURGH IN
47630-2529
US

IV. Provider business mailing address

7722 W STATE ROUTE 66
NEWBURGH IN
47630-2529
US

V. Phone/Fax

Practice location:
  • Phone: 812-853-6166
  • Fax:
Mailing address:
  • Phone: 812-853-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026765A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: