Provider Demographics
NPI:1457997850
Name:PORTER, KIM (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:79250
Mailing Address - Country:US
Mailing Address - Phone:806-667-2231
Mailing Address - Fax:806-667-0170
Practice Address - Street 1:1522 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:TX
Practice Address - Zip Code:79250
Practice Address - Country:US
Practice Address - Phone:806-667-2231
Practice Address - Fax:806-667-0170
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2350333600000X
TX20809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140165Medicaid