1215053004 NPI number — DR. KIMBERLY KAYE DAUGHERTY PHARMD

Table of content: DR. KIMBERLY KAYE DAUGHERTY PHARMD (NPI 1215053004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215053004 NPI number — DR. KIMBERLY KAYE DAUGHERTY PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
KIMBERLY
Provider Middle Name:
KAYE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215053004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 ROSEWOOD AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49506-5268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-452-6773
Provider Business Mailing Address Fax Number:
616-391-3783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 MICHIGAN ST NE STE 425
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-2530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-391-2728
Provider Business Practice Location Address Fax Number:
616-391-3783
Provider Enumeration Date:
03/22/2007

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: 1835P1200X , with the licence number:  5302034354 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1835P1200X , with the licence number: 011988 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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