Healthcare Provider Details

I. General information

NPI: 1700210085
Provider Name (Legal Business Name): KIMBERLY DAWN PUCKETT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 BONNER MALL WAY
PONDERAY ID
83852-9748
US

IV. Provider business mailing address

212 BONNER MALL WAY
PONDERAY ID
83852-9748
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-8066
  • Fax: 208-263-6623
Mailing address:
  • Phone: 208-255-8066
  • Fax: 208-263-6623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5173
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: