1871192153 NPI number — KIMBERLY BOREN MCDONOUGH PHARM D

Table of content: KIMBERLY BOREN MCDONOUGH PHARM D (NPI 1871192153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871192153 NPI number — KIMBERLY BOREN MCDONOUGH PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONOUGH
Provider First Name:
KIMBERLY
Provider Middle Name:
BOREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOODY
Provider Other First Name:
KIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARM D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871192153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 EDGEHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72207-5462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-831-4820
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 WEST 7TH STREET
Provider Second Line Business Practice Location Address:
ST 119/LR
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-831-4820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PD08047 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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