Provider Demographics
NPI:1942346069
Name:MERRITT, KIMBERLY KAY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:MERRITT
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 1:300 FERNBANK RD
Mailing Address - Street 2:
Mailing Address - City:STEENS
Mailing Address - State:MS
Mailing Address - Zip Code:39766-9664
Mailing Address - Country:US
Mailing Address - Phone:662-327-1742
Mailing Address - Fax:
Practice Address - Street 1:2211 5TH ST N STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2211
Practice Address - Country:US
Practice Address - Phone:662-240-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-08874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08507729Medicaid
MS48703300Medicare ID - Type Unspecified