Provider Demographics
NPI:1659976371
Name:KIMMONS, COURTNEY J (PHARMD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:J
Last Name:KIMMONS
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 1:2004 CHAMPIONS WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-5464
Mailing Address - Country:US
Mailing Address - Phone:469-595-6601
Mailing Address - Fax:
Practice Address - Street 1:3724 N OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-6451
Practice Address - Country:US
Practice Address - Phone:954-396-3129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist