Provider Demographics
NPI:1629668363
Name:FONTENOT, KIMBERLY JANE (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JANE
Last Name:FONTENOT
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 1:8713 COLLINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5204
Mailing Address - Country:US
Mailing Address - Phone:512-550-9181
Mailing Address - Fax:
Practice Address - Street 1:3801 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-8171
Practice Address - Country:US
Practice Address - Phone:512-444-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist