Provider Demographics
NPI:1780908806
Name:GRISHAM, KIMBERLY ANNETTA
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNETTA
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNETTA
Other - Last Name:GRISHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARM D
Mailing Address - Street 1:2501 RED WHEAT DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-5319
Mailing Address - Country:US
Mailing Address - Phone:580-323-0157
Mailing Address - Fax:580-323-7976
Practice Address - Street 1:2501 RED WHEAT DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-5319
Practice Address - Country:US
Practice Address - Phone:580-323-0157
Practice Address - Fax:580-323-7976
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist