Provider Demographics
NPI:1699043158
Name:MCDONALD, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MCDONALD
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 1:3948 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1624
Mailing Address - Country:US
Mailing Address - Phone:251-345-3394
Mailing Address - Fax:
Practice Address - Street 1:3948 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1624
Practice Address - Country:US
Practice Address - Phone:251-345-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist