Provider Demographics
NPI:1063918001
Name:TOMBLIN, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:TOMBLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 CLAY JACK RD
Mailing Address - Street 2:
Mailing Address - City:RUSH
Mailing Address - State:KY
Mailing Address - Zip Code:41168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1257 CLAY JACK RD
Practice Address - Street 2:
Practice Address - City:RUSH
Practice Address - State:KY
Practice Address - Zip Code:41168
Practice Address - Country:US
Practice Address - Phone:304-942-5623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVIN0007920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVIN0007920OtherWV INTERN LICENSE