MEDICARE: MRS. KIM RICE GORE PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202007822	VA

General Provider Information

NPI Number	:	1841339587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM RICE GORE PHARMACIST

Provider Business Mailing Address
First Line	:	9071 MOUNT ZION RD
Second Line	:
City	:	JETERSVILLE
State	:	VA
Zip	:	23083-2213
Country	:	US
Telephone Number	:	804-561-3804
Fax Number	:

Provider Business Practice Location Address
First Line	:	2105 ACADEMY RD
Second Line	:	SUITE E
City	:	POWHATAN
State	:	VA
Zip	:	23139-5829
Country	:	US
Telephone Number	:	804-598-5028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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