Healthcare Provider Details

I. General information

NPI: 1144557646
Provider Name (Legal Business Name): DEANNA INEZ KEDICH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE STOP A
FORT LIBERTY NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE STOP A
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8922
  • Fax: 910-907-6069
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18726
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: