Provider Demographics
NPI:1790209450
Name:KIMBROUGH, STEPHEN ROBERT (CPHT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROBERT
Last Name:KIMBROUGH
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 JEAN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5307
Mailing Address - Country:US
Mailing Address - Phone:503-303-7373
Mailing Address - Fax:
Practice Address - Street 1:6025 JEAN RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5307
Practice Address - Country:US
Practice Address - Phone:503-303-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-0009301183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician