Provider Demographics
NPI:1164705125
Name:SURBER, KIERSTEN (DPH)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:SURBER
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MCLAUGHLIN DR
Mailing Address - Street 2:SUPER D PHARMACY
Mailing Address - City:MUNFORD
Mailing Address - State:TN
Mailing Address - Zip Code:38058-2624
Mailing Address - Country:US
Mailing Address - Phone:901-837-0183
Mailing Address - Fax:
Practice Address - Street 1:24 MCLAUGHLIN DR
Practice Address - Street 2:SUPER D PHARMACY
Practice Address - City:MUNFORD
Practice Address - State:TN
Practice Address - Zip Code:38058-2624
Practice Address - Country:US
Practice Address - Phone:901-837-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist