Provider Demographics
NPI:1598386351
Name:WIMBLEY, KATHERINE MACKENZIE WOOD (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MACKENZIE WOOD
Last Name:WIMBLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 HIGHLANDS DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6051
Mailing Address - Country:US
Mailing Address - Phone:336-413-5142
Mailing Address - Fax:
Practice Address - Street 1:791 ATLANTA ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4452
Practice Address - Country:US
Practice Address - Phone:770-992-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0288793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy