Healthcare Provider Details

I. General information

NPI: 1013485515
Provider Name (Legal Business Name): KIMBERLY M MELLENTHIN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY M MCDEVITT PHARMD

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 W GREENFIELD AVE STE 130
WEST ALLIS WI
53214-3953
US

IV. Provider business mailing address

10101 W GREENFIELD AVE STE 130
WEST ALLIS WI
53214-3953
US

V. Phone/Fax

Practice location:
  • Phone: 414-533-6600
  • Fax: 414-533-6601
Mailing address:
  • Phone: 414-533-6600
  • Fax: 414-533-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19638
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: