Provider Demographics
NPI:1578846986
Name:WOLLENHAUPT, KIMBERLY R
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:R
Last Name:WOLLENHAUPT
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 1:1800 W MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2619
Mailing Address - Country:US
Mailing Address - Phone:217-720-8931
Mailing Address - Fax:
Practice Address - Street 1:1800 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2619
Practice Address - Country:US
Practice Address - Phone:217-479-0693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist