Provider Demographics
NPI:1952455321
Name:IVEY, KIM (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:IVEY
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:N5241 US HWY 45
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-0249
Mailing Address - Country:US
Mailing Address - Phone:906-358-4905
Mailing Address - Fax:906-358-4929
Practice Address - Street 1:N5241 US HWY 45
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-0249
Practice Address - Country:US
Practice Address - Phone:906-358-4905
Practice Address - Fax:906-358-4929
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist