Provider Demographics
NPI:1821379496
Name:MAXAM, KIMBERLY ANN (RPH)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MAXAM
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 1:139 N. GRAND ST., PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-0399
Mailing Address - Country:US
Mailing Address - Phone:269-679-2008
Mailing Address - Fax:269-679-2722
Practice Address - Street 1:139 N GRAND ST
Practice Address - Street 2:
Practice Address - City:SCHOOLCRAFT
Practice Address - State:MI
Practice Address - Zip Code:49087-5111
Practice Address - Country:US
Practice Address - Phone:269-679-2008
Practice Address - Fax:269-679-2722
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist