Provider Demographics
NPI:1093142044
Name:KUBESCH, KAILEY
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:KUBESCH
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 1:2235 BEMISS RD
Mailing Address - Street 2:APT 1-6
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 N OAK STREET EXT
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-6473
Practice Address - Country:US
Practice Address - Phone:229-247-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-06
Last Update Date:2013-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist