Provider Demographics
NPI:1336481894
Name:WHEELER, KIM D (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:D
Last Name:WHEELER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 NE 236TH PL
Mailing Address - Street 2:
Mailing Address - City:WOOD VILLAGE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-2768
Mailing Address - Country:US
Mailing Address - Phone:503-254-7383
Mailing Address - Fax:503-254-4568
Practice Address - Street 1:1125 NE 99TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-254-7383
Practice Address - Fax:503-254-4568
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0006537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0006537OtherPHARMACIST LICENSE
ORRPH-0006537-POtherPHARMACY PRECEPTOR LICENSE