Provider Demographics
NPI:1386011872
Name:KIPPENBERGER, MICHAEL P
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:KIPPENBERGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BROADWAY
Mailing Address - Street 2:1116
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-2077
Mailing Address - Country:US
Mailing Address - Phone:617-416-4630
Mailing Address - Fax:
Practice Address - Street 1:500 BROADWAY
Practice Address - Street 2:1116
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-2077
Practice Address - Country:US
Practice Address - Phone:617-416-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26163183500000X
CTPCT 9706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist