Provider Demographics
NPI:1972140705
Name:BEAUREGARD, KIMBERLY
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
Last Name:BEAUREGARD
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 1:33523 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4117
Mailing Address - Country:US
Mailing Address - Phone:248-473-8240
Mailing Address - Fax:248-474-9810
Practice Address - Street 1:33523 8 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4117
Practice Address - Country:US
Practice Address - Phone:248-473-8240
Practice Address - Fax:248-474-9810
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020279461835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist