Provider Demographics
NPI:1902272545
Name:WHITE-FAULL, KIMBERLY (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WHITE-FAULL
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 1:1450 EASTSIDE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-9800
Mailing Address - Country:US
Mailing Address - Phone:608-342-6200
Mailing Address - Fax:
Practice Address - Street 1:1450 EASTSIDE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9800
Practice Address - Country:US
Practice Address - Phone:608-342-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12164-40183500000X
IA20089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist