Provider Demographics
NPI:1720363062
Name:MCGARY, KIM L (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:MCGARY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8478 S YELLOWSTONE HWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5810
Mailing Address - Country:US
Mailing Address - Phone:208-524-4803
Mailing Address - Fax:
Practice Address - Street 1:535 E 17TH ST
Practice Address - Street 2:WALGREENS #05839
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6154
Practice Address - Country:US
Practice Address - Phone:208-542-4569
Practice Address - Fax:208-542-5007
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist