Healthcare Provider Details

I. General information

NPI: 1780331231
Provider Name (Legal Business Name): KIMBERLY MAE MIRANDA MOLL LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 06/06/2022
Certification Date: 05/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N MAIN ST
TUBA CITY AZ
86045
US

IV. Provider business mailing address

710 THREE CHIMNEYS WAY
OAKDALE CA
95361-7781
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2754
  • Fax: 928-283-2758
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: