Provider Demographics
NPI:1245716711
Name:KIMBLE, MERWYN BRADLEY JR
Entity type:Individual
Prefix:
First Name:MERWYN
Middle Name:BRADLEY
Last Name:KIMBLE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10070 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-4024
Mailing Address - Country:US
Mailing Address - Phone:314-631-6781
Mailing Address - Fax:
Practice Address - Street 1:10070 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-4024
Practice Address - Country:US
Practice Address - Phone:314-631-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist