Provider Demographics
NPI:1669344685
Name:KETCHUM, CAMERON
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11291 US HIGHWAY 98 E
Mailing Address - Street 2:
Mailing Address - City:INLET BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32461-9644
Mailing Address - Country:US
Mailing Address - Phone:850-213-7030
Mailing Address - Fax:
Practice Address - Street 1:11291 US HIGHWAY 98 E
Practice Address - Street 2:
Practice Address - City:INLET BEACH
Practice Address - State:FL
Practice Address - Zip Code:32461-9644
Practice Address - Country:US
Practice Address - Phone:850-213-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS69593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist