Provider Demographics
NPI:1073976163
Name:WITBRODT, KEVIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:WITBRODT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 AUSTIN PEAY HWY
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2501
Mailing Address - Country:US
Mailing Address - Phone:901-383-4847
Mailing Address - Fax:901-383-4848
Practice Address - Street 1:2835 KIRBY RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8209
Practice Address - Country:US
Practice Address - Phone:901-353-1387
Practice Address - Fax:901-353-5974
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE131111835P0018X
TN375621835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist