Basic Information
Provider Information | |||||||||
NPI: | 1972170942 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOVAK | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD, BCPS, BCPPS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 CHILDRENS DR | ||||||||
Address2: | DEPARTMENT OF PHARMACY | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432052639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6147222199 | ||||||||
FaxNumber: | 6147222189 | ||||||||
Practice Location | |||||||||
Address1: | 700 CHILDRENS DR | ||||||||
Address2: | DEPARTMENT OF PHARMACY | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432052639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6147222199 | ||||||||
FaxNumber: | 6147222189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2021 | ||||||||
LastUpdateDate: | 06/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0200X | 012413 | KY | N |   |   |   |   | 1835P0200X | 03-02-26488 | OH | Y |   |   |   |   |
No ID Information.