Provider Demographics
NPI:1427216951
Name:KILBOURN, JOHN WALLACE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WALLACE
Last Name:KILBOURN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3022
Mailing Address - Country:US
Mailing Address - Phone:360-575-6605
Mailing Address - Fax:360-575-6608
Practice Address - Street 1:3138 VIRGINIA WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-5419
Practice Address - Country:US
Practice Address - Phone:360-577-4547
Practice Address - Fax:360-575-6608
Is Sole Proprietor?:No
Enumeration Date:2008-05-31
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist