Provider Demographics
NPI:1942892484
Name:HENDERSON, KIMBERLY COLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:COLEY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:COLEY
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:15 POINTE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-2755
Mailing Address - Country:US
Mailing Address - Phone:404-271-8768
Mailing Address - Fax:404-592-9018
Practice Address - Street 1:1790 MULKEY RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1122
Practice Address - Country:US
Practice Address - Phone:770-693-9388
Practice Address - Fax:770-693-9537
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist