Provider Demographics
NPI:1013759422
Name:MINER, KIMBERLY (CPHT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MINER
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 GROSSMONT CENTER DR STE A217
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3019
Mailing Address - Country:US
Mailing Address - Phone:619-740-4451
Mailing Address - Fax:619-740-4354
Practice Address - Street 1:5555 GROSSMONT CENTER DR STE A217
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-4451
Practice Address - Fax:619-740-4354
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79553183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician