Provider Demographics
NPI:1346562675
Name:HENLEY, KIMBERLY SHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHAN
Last Name:HENLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 E MAIN ST
Mailing Address - Street 2:ATTENTION: PHARMACY DEPT.
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-3488
Mailing Address - Country:US
Mailing Address - Phone:276-228-3177
Mailing Address - Fax:276-228-0524
Practice Address - Street 1:1480 E MAIN ST
Practice Address - Street 2:ATTENTION: PHARMACY DEPT.
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-3488
Practice Address - Country:US
Practice Address - Phone:276-228-3177
Practice Address - Fax:276-228-0524
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist