1467546028 NPI number — MRS. PAMELA GRISHAM KILGORE RPH

Table of content: MRS. PAMELA GRISHAM KILGORE RPH (NPI 1467546028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467546028 NPI number — MRS. PAMELA GRISHAM KILGORE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILGORE
Provider First Name:
PAMELA
Provider Middle Name:
GRISHAM
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1467546028
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:
209 SPEIGHT AVE #214
Provider Second Line Business Mailing Address:
MCLANE STUDENT LIFE COMPLEX - PHARMACY
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-710-4268
Provider Business Mailing Address Fax Number:
254-710-3620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 SPEIGHT AVE #214
Provider Second Line Business Practice Location Address:
MCLANE STUDENT LIFE COMPLEX - PHARMACY
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-710-4268
Provider Business Practice Location Address Fax Number:
254-710-3620
Provider Enumeration Date:
10/03/2006

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:  29050 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 29050 . This is a "TEXAS RPH LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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