Provider Demographics
NPI:1518506047
Name:KIMBALL, KEN A (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:A
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 HARDISTY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2802 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4733
Practice Address - Country:US
Practice Address - Phone:260-471-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-01
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016357A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist