Provider Demographics
NPI:1871919373
Name:KIMMEL-SULLIVAN, BEVERLY (RPH)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:KIMMEL-SULLIVAN
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 1:3728 N. PRINCE STREET
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-2389
Mailing Address - Fax:575-769-2495
Practice Address - Street 1:3728 N. PRINCE STREET
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-2389
Practice Address - Fax:575-769-2495
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist