Provider Demographics
NPI:1629194303
Name:KIBBLE, MICHAEL WILLIAM (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:KIBBLE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-9120
Mailing Address - Country:US
Mailing Address - Phone:530-283-0480
Mailing Address - Fax:530-283-1410
Practice Address - Street 1:493 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9120
Practice Address - Country:US
Practice Address - Phone:530-283-0480
Practice Address - Fax:530-283-1410
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH37484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH37484OtherSTATE PHARMACIST LICENSE