Provider Demographics
NPI:1184037731
Name:KISHBAUGH, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:KISHBAUGH
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 1:452 S LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-2414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:452 S LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-2414
Practice Address - Country:US
Practice Address - Phone:570-874-1587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP447810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist