Provider Demographics
NPI:1154603199
Name:DEITEMEYER, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DEITEMEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-2309
Mailing Address - Country:US
Mailing Address - Phone:859-881-8203
Mailing Address - Fax:
Practice Address - Street 1:901 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2309
Practice Address - Country:US
Practice Address - Phone:859-881-8203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist