MEDICARE: JACLYN DIANE KIRKPATRICK

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	16343	AL

General Provider Information

NPI Number	:	1710582861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN DIANE KIRKPATRICK

Provider Business Mailing Address
First Line	:	4941 MONTEVALLO RD
Second Line	:
City	:	IRONDALE
State	:	AL
Zip	:	35210-2418
Country	:	US
Telephone Number	:	205-820-7626
Fax Number	:

Provider Business Practice Location Address
First Line	:	4941 MONTEVALLO RD
Second Line	:
City	:	IRONDALE
State	:	AL
Zip	:	35210-2418
Country	:	US
Telephone Number	:	205-820-7626
Fax Number	:

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

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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