Provider Demographics
NPI:1790392363
Name:KNUCKLES, KIMBERLY DAWN (BS PHARMACY)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:KNUCKLES
Suffix:
Gender:F
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 BOBCAT LN
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-9601
Mailing Address - Country:US
Mailing Address - Phone:304-575-3441
Mailing Address - Fax:
Practice Address - Street 1:163 BEAVER PLZ
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-8400
Practice Address - Country:US
Practice Address - Phone:304-255-6630
Practice Address - Fax:304-256-0524
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist