Provider Demographics
NPI:1700449154
Name:MIRE, KIMBERLY (RPH)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:MIRE
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:PO BOX 542439
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33454-2439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-8656
Practice Address - Country:US
Practice Address - Phone:561-600-3095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-20
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30867183500000X
FLPS24967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL577880OtherNABP