Provider Demographics
NPI:1093296204
Name:WETHERHOLT, KIM MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:WETHERHOLT
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 1:1415 PADDLE WHEEL LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4241
Mailing Address - Country:US
Mailing Address - Phone:568-786-9768
Mailing Address - Fax:
Practice Address - Street 1:6700 N ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48306-4362
Practice Address - Country:US
Practice Address - Phone:248-601-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist