Provider Demographics
NPI:1962508002
Name:O'NEILL, KIMBERLY DENICE (PD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DENICE
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 1165
Mailing Address - Street 2:
Mailing Address - City:MYRTLE
Mailing Address - State:MO
Mailing Address - Zip Code:65778-9743
Mailing Address - Country:US
Mailing Address - Phone:417-938-4457
Mailing Address - Fax:870-892-2592
Practice Address - Street 1:115 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-3402
Practice Address - Country:US
Practice Address - Phone:870-892-5675
Practice Address - Fax:870-892-2592
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR07646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist