Provider Demographics
NPI:1154752988
Name:KIMBALL, BONNY
Entity type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:KIMBALL
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 1:5152 ANTON DR
Mailing Address - Street 2:213
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1772
Mailing Address - Country:US
Mailing Address - Phone:608-217-4551
Mailing Address - Fax:
Practice Address - Street 1:5152 ANTON DR
Practice Address - Street 2:213
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53719-1772
Practice Address - Country:US
Practice Address - Phone:608-217-4551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14533-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist