Healthcare Provider Details

I. General information

NPI: 1528511763
Provider Name (Legal Business Name): KIMBERLY GAINES PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2016
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E LINCOLN RD
IDABEL OK
74745-7337
US

IV. Provider business mailing address

PO BOX 213
MILLERTON OK
74750-0213
US

V. Phone/Fax

Practice location:
  • Phone: 580-286-2600
  • Fax: 580-286-4714
Mailing address:
  • Phone: 405-420-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16973
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: