Provider Demographics
NPI:1548892268
Name:GARDNER, KIMBERLY
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6387 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9441
Mailing Address - Country:US
Mailing Address - Phone:910-615-3900
Mailing Address - Fax:
Practice Address - Street 1:4205 FERNCREEK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2537
Practice Address - Country:US
Practice Address - Phone:910-551-3378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC168183336C0003X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy