Provider Demographics
NPI:1497256242
Name:WELLS, KIM DENISE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DENISE
Last Name:WELLS
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 1:3003 S LOOP W STE 450
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-1315
Mailing Address - Country:US
Mailing Address - Phone:281-652-8080
Mailing Address - Fax:281-652-1438
Practice Address - Street 1:1580 GREENSMARK DR APT 135
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77067-4009
Practice Address - Country:US
Practice Address - Phone:281-652-8080
Practice Address - Fax:281-652-1438
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX267743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy