Provider Demographics
NPI:1821690728
Name:WIETER, KIMBERLY (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WIETER
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 1:1071 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5309
Mailing Address - Country:US
Mailing Address - Phone:618-532-2200
Mailing Address - Fax:618-533-0566
Practice Address - Street 1:1071 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5309
Practice Address - Country:US
Practice Address - Phone:618-532-2200
Practice Address - Fax:618-533-0566
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist