Provider Demographics
NPI:1215222773
Name:MCKIBBAN, BROCK MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:MICHAEL
Last Name:MCKIBBAN
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 1:11148 PLUM DR
Mailing Address - Street 2:TARGET PHARMACY STORE NUMBER T-1791
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-6328
Mailing Address - Country:US
Mailing Address - Phone:515-270-6884
Mailing Address - Fax:
Practice Address - Street 1:11148 PLUM DR
Practice Address - Street 2:TARGET PHARMACY STORE NUMBER T-1791
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-6328
Practice Address - Country:US
Practice Address - Phone:515-270-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist