Provider Demographics
NPI:1477621977
Name:TANNER, KIM L (RPH BCOP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:TANNER
Suffix:
Gender:F
Credentials:RPH BCOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3884
Mailing Address - Country:US
Mailing Address - Phone:972-459-1390
Mailing Address - Fax:972-459-1391
Practice Address - Street 1:2790 LAKE VISTA DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3884
Practice Address - Country:US
Practice Address - Phone:972-459-1390
Practice Address - Fax:972-459-1391
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX330591835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology