Provider Demographics
NPI:1376823005
Name:AVERILL, KIMALYN SUE (RPH)
Entity Type:Individual
Prefix:MS
First Name:KIMALYN
Middle Name:SUE
Last Name:AVERILL
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 1:2281 BRIDLE CREEK ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-0957
Mailing Address - Country:US
Mailing Address - Phone:616-745-9213
Mailing Address - Fax:
Practice Address - Street 1:3191 28TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1110
Practice Address - Country:US
Practice Address - Phone:616-534-5533
Practice Address - Fax:616-534-2205
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030463183500000X
FLPS42372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist