Provider Demographics
NPI:1275135048
Name:KIEBALA, RICHARD JEFFREY (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JEFFREY
Last Name:KIEBALA
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 1:4801 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3211
Mailing Address - Country:US
Mailing Address - Phone:773-282-2828
Mailing Address - Fax:773-282-9120
Practice Address - Street 1:4801 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3211
Practice Address - Country:US
Practice Address - Phone:773-282-2828
Practice Address - Fax:773-282-9120
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist