Provider Demographics
NPI:1720289002
Name:LINDSTROM, KIMBERLI D (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:D
Last Name:LINDSTROM
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 1:40 CORMORANT CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-8705
Mailing Address - Country:US
Mailing Address - Phone:386-788-7781
Mailing Address - Fax:
Practice Address - Street 1:239 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1734
Practice Address - Country:US
Practice Address - Phone:386-423-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist