Provider Demographics
NPI:1568949931
Name:STAFFORD, KIM (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:STAFFORD
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 1:455 ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2325
Mailing Address - Country:US
Mailing Address - Phone:401-480-6951
Mailing Address - Fax:
Practice Address - Street 1:330 RUTHERFORD AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-2932
Practice Address - Country:US
Practice Address - Phone:617-681-7107
Practice Address - Fax:617-326-5123
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH21707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist