MEDICARE: KATHRYN LEIGH KETTLER PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PSI36597	FL

General Provider Information

NPI Number	:	1134746357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN LEIGH KETTLER PHARMD

Provider Business Mailing Address
First Line	:	4836 BRIERWOOD RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-8027
Country	:	US
Telephone Number	:	386-793-3945
Fax Number	:

Provider Business Practice Location Address
First Line	:	4836 BRIERWOOD RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-8027
Country	:	US
Telephone Number	:	386-793-3945
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2020
Last Update Date	:	07/03/2020

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