Provider Demographics
NPI:1679275952
Name:KIBERU, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KIBERU
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 1:28319 CASCADE RD
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-4733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1438
Practice Address - Country:US
Practice Address - Phone:747-210-3059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist