Provider Demographics
NPI:1356066054
Name:AMMERMAN, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:AMMERMAN
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 1:11600 LOFTY PINES RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SD
Mailing Address - Zip Code:57769-7218
Mailing Address - Country:US
Mailing Address - Phone:605-578-1512
Mailing Address - Fax:
Practice Address - Street 1:71 CHARLES ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-1303
Practice Address - Country:US
Practice Address - Phone:605-578-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR5122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist