Provider Demographics
NPI:1104426709
Name:IBISEVIC, FATA (PHARMD)
Entity type:Individual
Prefix:
First Name:FATA
Middle Name:
Last Name:IBISEVIC
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 NASHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134-6962
Mailing Address - Country:US
Mailing Address - Phone:270-586-0022
Mailing Address - Fax:
Practice Address - Street 1:1550 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-6962
Practice Address - Country:US
Practice Address - Phone:270-586-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY020226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist