Provider Demographics
NPI:1356072292
Name:PERKINS, AVIS KATHLEEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:AVIS
Middle Name:KATHLEEN
Last Name:PERKINS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:104 E WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5832
Mailing Address - Country:US
Mailing Address - Phone:770-490-1038
Mailing Address - Fax:
Practice Address - Street 1:4025 S OLD STATE ROAD 37
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7482
Practice Address - Country:US
Practice Address - Phone:812-824-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA180211835P0018X
FLPS473801835P0018X
TX96021601835P0018X
MO20110118001835P0018X
INCV2208861835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA18021OtherGEORGIA BOARD OF PHARMACY
MO2011011800OtherMISSOURI BOARD OF PHARMACY
FLPS47380OtherFLORIDA BOARD OF PHARMACY
TX9602160OtherTEXAS BOARD OF PHARMACY
266570OtherNABP