Provider Demographics
NPI:1215053004
Name:DAUGHERTY, KIMBERLY KAYE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KAYE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 ROSEWOOD AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-5268
Mailing Address - Country:US
Mailing Address - Phone:616-452-6773
Mailing Address - Fax:616-391-3783
Practice Address - Street 1:21 MICHIGAN ST NE STE 425
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2530
Practice Address - Country:US
Practice Address - Phone:616-391-2728
Practice Address - Fax:616-391-3783
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020343541835P1200X
KY0119881835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy