Provider Demographics
NPI:1356627210
Name:KIBODEAUX, SAMANTHA DIANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:DIANE
Last Name:KIBODEAUX
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 HIGHWAY 332 W
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4013
Mailing Address - Country:US
Mailing Address - Phone:979-299-2330
Mailing Address - Fax:979-299-1159
Practice Address - Street 1:202 HIGHWAY 332 W
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4013
Practice Address - Country:US
Practice Address - Phone:979-299-2330
Practice Address - Fax:979-299-1159
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist