Provider Demographics
NPI:1083601496
Name:KIBBLE ENTERPRISES INC
Entity Type:Organization
Organization Name:KIBBLE ENTERPRISES INC
Other - Org Name:QUINCY DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:530-283-0480
Mailing Address - Street 1:157 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-9606
Mailing Address - Country:US
Mailing Address - Phone:530-832-4218
Mailing Address - Fax:530-283-1410
Practice Address - Street 1:493 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9120
Practice Address - Country:US
Practice Address - Phone:530-832-4218
Practice Address - Fax:530-832-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
CAPHY465833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2076757OtherPK
CAPHA465830Medicaid
5071690001Medicare NSC