Provider Demographics
NPI:1396181657
Name:RAGAN, KIM DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DAVID
Last Name:RAGAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 STONEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2967
Mailing Address - Country:US
Mailing Address - Phone:678-378-3300
Mailing Address - Fax:901-284-0113
Practice Address - Street 1:150 STONEHAVEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2967
Practice Address - Country:US
Practice Address - Phone:678-378-3300
Practice Address - Fax:901-284-0113
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016377183500000X
MO040314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist