Provider Demographics
NPI:1508580093
Name:NIBA, BRAIN FUBI (RPH)
Entity Type:Individual
Prefix:
First Name:BRAIN
Middle Name:FUBI
Last Name:NIBA
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 1:13704 S BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-2098
Mailing Address - Country:US
Mailing Address - Phone:405-549-6162
Mailing Address - Fax:
Practice Address - Street 1:9000 S MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6602
Practice Address - Country:US
Practice Address - Phone:405-691-1148
Practice Address - Fax:405-691-5426
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist