Provider Demographics
NPI:1073813523
Name:RUSCOE, KIMBERLY P
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:P
Last Name:RUSCOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 RUSSELL FARMS RD
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-5800
Mailing Address - Country:US
Mailing Address - Phone:901-672-2684
Mailing Address - Fax:901-758-3632
Practice Address - Street 1:7735 FARMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2901
Practice Address - Country:US
Practice Address - Phone:901-754-7864
Practice Address - Fax:901-758-3632
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8134183500000X
MST-010468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist