Provider Demographics
NPI:1417552084
Name:IGO, KIMBERLY BETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BETH
Last Name:IGO
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 1:261 CHAUNCY ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-1247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:261 CHAUNCY ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1247
Practice Address - Country:US
Practice Address - Phone:508-339-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH235277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist