Provider Demographics
NPI:1225419104
Name:OLIVER, KIMBERLY DAWN (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:OLIVER
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 1:107 KOONTZ AVE
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-9578
Mailing Address - Country:US
Mailing Address - Phone:304-548-2155
Mailing Address - Fax:
Practice Address - Street 1:107 KOONTZ AVE
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-9578
Practice Address - Country:US
Practice Address - Phone:304-548-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0005687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist