Provider Demographics
NPI:1588235279
Name:ELIASON, KIMBERLY LOUISE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LOUISE
Last Name:ELIASON
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 1:1401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1562
Mailing Address - Country:US
Mailing Address - Phone:616-897-9221
Mailing Address - Fax:616-897-9046
Practice Address - Street 1:1401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1562
Practice Address - Country:US
Practice Address - Phone:616-897-9221
Practice Address - Fax:616-897-9046
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303026117183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician