Provider Demographics
NPI:1629505672
Name:CORLESS, KIMBERLY ANN (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:CORLESS
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 1:275 HIGHLAND AVE # 695
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2522
Mailing Address - Country:US
Mailing Address - Phone:203-272-3697
Mailing Address - Fax:203-272-7823
Practice Address - Street 1:275 HIGHLAND AVE # 695
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2522
Practice Address - Country:US
Practice Address - Phone:203-272-3697
Practice Address - Fax:203-272-7823
Is Sole Proprietor?:No
Enumeration Date:2017-05-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist