Provider Demographics
NPI:1578974739
Name:KILLINGBECK, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:KILLINGBECK
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 1:1920 PIPESTONE RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2315
Mailing Address - Country:US
Mailing Address - Phone:269-934-6733
Mailing Address - Fax:269-934-6765
Practice Address - Street 1:1920 PIPESTONE RD
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2315
Practice Address - Country:US
Practice Address - Phone:269-934-6733
Practice Address - Fax:269-934-6765
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020230621835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2329616Medicaid