Provider Demographics
NPI:1720320260
Name:ALLEN, KIMBERLY GARY (RPH)
Entity type:Individual
Prefix:MR
First Name:KIMBERLY
Middle Name:GARY
Last Name:ALLEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 N 1ST E
Mailing Address - Street 2:PHARMACY
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1326
Mailing Address - Country:US
Mailing Address - Phone:208-852-4129
Mailing Address - Fax:208-852-3812
Practice Address - Street 1:44 N 1ST E
Practice Address - Street 2:PHARMACY
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1326
Practice Address - Country:US
Practice Address - Phone:208-852-4129
Practice Address - Fax:208-852-3812
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4491183500000X
CARPH 43613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist