Provider Demographics
NPI:1396121570
Name:MCCRARY, KIERRA WATSON
Entity type:Individual
Prefix:
First Name:KIERRA
Middle Name:WATSON
Last Name:MCCRARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3616 PINE OAK CIR APT 104
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7440
Mailing Address - Country:US
Mailing Address - Phone:954-648-6679
Mailing Address - Fax:
Practice Address - Street 1:6790 DANIELS PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7521
Practice Address - Country:US
Practice Address - Phone:239-433-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist