Provider Demographics
NPI:1992196497
Name:PARK, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PARK
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 1:57 BEST RD
Mailing Address - Street 2:
Mailing Address - City:HARPERS FERRY
Mailing Address - State:WV
Mailing Address - Zip Code:25425-5270
Mailing Address - Country:US
Mailing Address - Phone:304-261-1727
Mailing Address - Fax:
Practice Address - Street 1:436 RETAIL COMMONS PKWY
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-6183
Practice Address - Country:US
Practice Address - Phone:304-264-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT0006236183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician