Healthcare Provider Details

I. General information

NPI: 1215053004
Provider Name (Legal Business Name): KIMBERLY KAYE DAUGHERTY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MICHIGAN ST NE STE 425
GRAND RAPIDS MI
49503-2530
US

IV. Provider business mailing address

2301 ROSEWOOD AVE SE
GRAND RAPIDS MI
49506-5268
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-2728
  • Fax: 616-391-3783
Mailing address:
  • Phone: 616-452-6773
  • Fax: 616-391-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number5302034354
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number011988
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: