Provider Demographics
NPI:1437575123
Name:FEDDERLY, KIMBERLY (PHARMD, MS HN)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:FEDDERLY
Suffix:
Gender:F
Credentials:PHARMD, MS HN
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:HOPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:103 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6833
Mailing Address - Country:US
Mailing Address - Phone:406-270-7957
Mailing Address - Fax:406-755-8432
Practice Address - Street 1:103 PONDEROSA LN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6833
Practice Address - Country:US
Practice Address - Phone:406-270-7957
Practice Address - Fax:406-755-8432
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011376183500000X
MT49251835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No183500000XPharmacy Service ProvidersPharmacist