Provider Demographics
NPI:1427505601
Name:WHEATLEY, KIMBERLY (RPH)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1526
Mailing Address - Country:US
Mailing Address - Phone:502-348-9261
Mailing Address - Fax:502-348-3334
Practice Address - Street 1:102 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1526
Practice Address - Country:US
Practice Address - Phone:502-348-9261
Practice Address - Fax:502-348-3334
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist