Provider Demographics
NPI:1073379707
Name:JACKSON-GRUNDY, KIMBERLY LATRICE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LATRICE
Last Name:JACKSON-GRUNDY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 HAUSFELDT LN APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150
Mailing Address - Country:US
Mailing Address - Phone:502-501-8092
Mailing Address - Fax:
Practice Address - Street 1:816 HAUSFELDT LN APT 4
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150
Practice Address - Country:US
Practice Address - Phone:502-501-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45023649A183500000X
KYI15738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist