Provider Demographics
NPI:1497035935
Name:HINES, KIMBERLY JANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JANE
Last Name:HINES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 SILVER FARMS LN
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8827
Mailing Address - Country:US
Mailing Address - Phone:231-995-0039
Mailing Address - Fax:
Practice Address - Street 1:975 W SOUTH AIRPORT RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4846
Practice Address - Country:US
Practice Address - Phone:231-946-5840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist