MEDICARE: KURT M IKETANI PHARMACIST

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	PS21717	FL

General Provider Information

NPI Number	:	1801134374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KURT M IKETANI PHARMACIST

Provider Business Mailing Address
First Line	:	3450 E SILVER SPRINGS BLVD
Second Line	:
City	:	OCALA
State	:	FL
Zip	:	34470-6406
Country	:	US
Telephone Number	:	352-671-3770
Fax Number	:	352-671-3771

Provider Business Practice Location Address
First Line	:	3450 E SILVER SPRINGS BLVD
Second Line	:
City	:	OCALA
State	:	FL
Zip	:	34470-6406
Country	:	US
Telephone Number	:	352-671-3770
Fax Number	:	352-671-3771

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

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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