=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538696562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY JOY POLEGAY PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2017
-----------------------------------------------------
Last Update Date | 05/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 S KOLB RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85710-8427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-329-6472
-----------------------------------------------------
Fax | 520-329-6473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8545 S LONG BAR RANCH PL
-----------------------------------------------------
City | VAIL
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85641-8954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-732-1190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S017379
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------