Provider Demographics
NPI:1720509151
Name:MOUTON, KIM GERARD
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:GERARD
Last Name:MOUTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 LAKE VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5031
Mailing Address - Country:US
Mailing Address - Phone:281-468-1078
Mailing Address - Fax:
Practice Address - Street 1:4131 LAKE VISTA CIR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5031
Practice Address - Country:US
Practice Address - Phone:281-468-1078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX288811835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care