Provider Demographics
NPI:1861778243
Name:PEARSON, KIM MICHELLE
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MICHELLE
Last Name:PEARSON
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 1:3890 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4800
Mailing Address - Country:US
Mailing Address - Phone:813-269-2814
Mailing Address - Fax:813-265-4317
Practice Address - Street 1:3890 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4800
Practice Address - Country:US
Practice Address - Phone:813-269-2814
Practice Address - Fax:813-265-4317
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0034213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist