Provider Demographics
NPI:1982146635
Name:POUGH, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:POUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3109
Mailing Address - Country:US
Mailing Address - Phone:631-254-0464
Mailing Address - Fax:
Practice Address - Street 1:1200 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-3109
Practice Address - Country:US
Practice Address - Phone:631-254-0464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist