Provider Demographics
NPI:1891080420
Name:TELENKO, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TELENKO
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 1:29451 PLYMOUTH RD
Mailing Address - Street 2:T-2230
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29451 PLYMOUTH RD
Practice Address - Street 2:T-2230
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2112
Practice Address - Country:US
Practice Address - Phone:734-793-0638
Practice Address - Fax:734-793-0648
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-11
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist