Provider Demographics
NPI:1013485515
Name:MELLENTHIN, KIMBERLY M (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:MELLENTHIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:MCDEVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:10101 W GREENFIELD AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3953
Mailing Address - Country:US
Mailing Address - Phone:414-533-6600
Mailing Address - Fax:414-533-6601
Practice Address - Street 1:10101 W GREENFIELD AVE STE 130
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3953
Practice Address - Country:US
Practice Address - Phone:414-533-6600
Practice Address - Fax:414-533-6601
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist