Provider Demographics
NPI:1225636111
Name:DITTBERNER, KAYLEE (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:DITTBERNER
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:
Other - Last Name:SOMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH, PHARMD
Mailing Address - Street 1:1338 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1903
Mailing Address - Country:US
Mailing Address - Phone:651-792-6528
Mailing Address - Fax:
Practice Address - Street 1:5815 NORELL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-1766
Practice Address - Country:US
Practice Address - Phone:651-439-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1234461835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist