Provider Demographics
NPI:1669563003
Name:FAIRBANK, KIMBERLY MICHELLE (CPHT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:FAIRBANK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-2325
Mailing Address - Country:US
Mailing Address - Phone:541-751-0554
Mailing Address - Fax:
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2125
Practice Address - Country:US
Practice Address - Phone:541-269-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT0000480183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician