Provider Demographics
NPI:1619315025
Name:TIBALLI, KATEE E (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:KATEE
Middle Name:E
Last Name:TIBALLI
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MONTEZUMA ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489
Mailing Address - Country:US
Mailing Address - Phone:315-573-9748
Mailing Address - Fax:
Practice Address - Street 1:9 BROAD ST
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779
Practice Address - Country:US
Practice Address - Phone:716-945-1095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057877-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist