Provider Demographics
NPI:1003418864
Name:AUTH, KIMBERLEE SUE (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:SUE
Last Name:AUTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E 89TH ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5073
Mailing Address - Country:US
Mailing Address - Phone:309-830-1837
Mailing Address - Fax:
Practice Address - Street 1:1569 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-4003
Practice Address - Country:US
Practice Address - Phone:212-249-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.286990183500000X
CA52294183500000X
NYI064109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
210521OtherNABP EPROFILE ID
NYI064109OtherPHARMACIST STATE LICENSE NUMBER