Provider Demographics
NPI:1447311246
Name:KIMBERLY PHARMACY, INC.
Entity type:Organization
Organization Name:KIMBERLY PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:VAN ASTEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-788-1940
Mailing Address - Street 1:110 E KIMBERLY AVE
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-1401
Mailing Address - Country:US
Mailing Address - Phone:920-788-1940
Mailing Address - Fax:920-788-3373
Practice Address - Street 1:110 E KIMBERLY AVE
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-1401
Practice Address - Country:US
Practice Address - Phone:920-788-1940
Practice Address - Fax:920-788-3373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5651-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5103887OtherNCPDP #
WI33078300Medicaid
WI5651-042OtherPHARMACY LICENSE #
WI33078300Medicaid