Provider Demographics
NPI:1558673707
Name:CONNER, KIM G (RPH MAC)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:G
Last Name:CONNER
Suffix:
Gender:M
Credentials:RPH MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 YELLOWWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4622
Mailing Address - Country:US
Mailing Address - Phone:410-592-2752
Mailing Address - Fax:443-327-6547
Practice Address - Street 1:4834 WATER PARK DR
Practice Address - Street 2:
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-1442
Practice Address - Country:US
Practice Address - Phone:443-838-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-04
Last Update Date:2010-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00671171100000X
MD120081835N1003X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist