Provider Demographics
NPI:1194042077
Name:IVY, KIM ANGELINA (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANGELINA
Last Name:IVY
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 1:9620 SLATE CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-2997
Mailing Address - Country:US
Mailing Address - Phone:512-238-6561
Mailing Address - Fax:
Practice Address - Street 1:651 N US HIGHWAY 183
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-8990
Practice Address - Country:US
Practice Address - Phone:512-528-7777
Practice Address - Fax:512-528-7780
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist