Provider Demographics
NPI:1740570191
Name:MOORE, KIMBERLY BLEVINS (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BLEVINS
Last Name:MOORE
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 1:29 S TERESA DR
Mailing Address - Street 2:
Mailing Address - City:OWINGSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40360-2010
Mailing Address - Country:US
Mailing Address - Phone:606-674-8532
Mailing Address - Fax:
Practice Address - Street 1:125 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380
Practice Address - Country:US
Practice Address - Phone:606-663-2521
Practice Address - Fax:606-663-7662
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist