Provider Demographics
NPI:1629694757
Name:MOREAU, KIMBERLYN GREGG
Entity Type:Individual
Prefix:
First Name:KIMBERLYN
Middle Name:GREGG
Last Name:MOREAU
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 1:2107 S LOOP 256
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-5919
Mailing Address - Country:US
Mailing Address - Phone:903-723-1092
Mailing Address - Fax:866-544-4584
Practice Address - Street 1:2107 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-5919
Practice Address - Country:US
Practice Address - Phone:903-723-1092
Practice Address - Fax:866-544-4584
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist