Provider Demographics
NPI:1821742255
Name:KIMBALL, LEE L
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:L
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 MOHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-9621
Mailing Address - Country:US
Mailing Address - Phone:413-774-3858
Mailing Address - Fax:413-774-2009
Practice Address - Street 1:237 MOHAWK TRL
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-9621
Practice Address - Country:US
Practice Address - Phone:413-774-3858
Practice Address - Fax:413-774-2009
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist