1083601496 NPI number — KIBBLE ENTERPRISES INC

Table of content: (NPI 1083601496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083601496 NPI number — KIBBLE ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIBBLE ENTERPRISES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
QUINCY DRUG STORE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083601496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 COMMERCIAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTOLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96122-9606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-832-4218
Provider Business Mailing Address Fax Number:
530-283-1410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
493 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95971-9120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-832-4218
Provider Business Practice Location Address Fax Number:
530-832-1375
Provider Enumeration Date:
09/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIBBLE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST OWNER
Authorized Official Telephone Number:
530-283-0480

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY46583 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2076757 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHA465830 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".