Provider Demographics
NPI:1467054619
Name:RUNNEBAUM, KACI
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:
Last Name:RUNNEBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 3RD PL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-5908
Mailing Address - Country:US
Mailing Address - Phone:785-587-8648
Mailing Address - Fax:
Practice Address - Street 1:601 3RD PL
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5908
Practice Address - Country:US
Practice Address - Phone:785-587-8648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist