Provider Demographics
NPI:1235732090
Name:OBERMARK, KIMBERLY JEAN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:OBERMARK
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 1:10729 S WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-6826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2760 N HIGHWAY 167
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2461
Practice Address - Country:US
Practice Address - Phone:918-379-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist