Provider Demographics
NPI:1467052225
Name:LIEBAU, KIMBERLY (RPH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LIEBAU
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 1:2900 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-8694
Mailing Address - Country:US
Mailing Address - Phone:304-489-3268
Mailing Address - Fax:
Practice Address - Street 1:2900 PIKE ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-8694
Practice Address - Country:US
Practice Address - Phone:304-489-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist