Provider Demographics
NPI:1245909134
Name:PORTER, KIMBERLY PAIGE (PHARMD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAIGE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4505
Mailing Address - Country:US
Mailing Address - Phone:662-226-6631
Mailing Address - Fax:662-226-6650
Practice Address - Street 1:329 SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4505
Practice Address - Country:US
Practice Address - Phone:662-226-6631
Practice Address - Fax:662-226-6650
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist