Provider Demographics
NPI:1003284613
Name:WHEATCRAFT, KIMBERLY MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:WHEATCRAFT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:CLIFTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1930 STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8345
Mailing Address - Country:US
Mailing Address - Phone:386-423-1173
Mailing Address - Fax:
Practice Address - Street 1:1930 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8345
Practice Address - Country:US
Practice Address - Phone:386-423-1173
Practice Address - Fax:386-423-9475
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS53964OtherDEPARTMENT OF HEALTH