Provider Demographics
NPI:1447561295
Name:KIMMONS, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:KIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:ADAMSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38310-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 PERKINS RD
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38310-2808
Practice Address - Country:US
Practice Address - Phone:731-632-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-27
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC6162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist