Healthcare Provider Details

I. General information

NPI: 1124664073
Provider Name (Legal Business Name): KIMBERLY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N AVON AVE
AVON IN
46123-8475
US

IV. Provider business mailing address

108 N AVON AVE
AVON IN
46123-8475
US

V. Phone/Fax

Practice location:
  • Phone: 317-272-4135
  • Fax: 317-347-8489
Mailing address:
  • Phone: 317-272-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26019343A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: