Provider Demographics
NPI:1679666002
Name:KIBBLE ENTERPRISES, INC.
Entity Type:Organization
Organization Name:KIBBLE ENTERPRISES, INC.
Other - Org Name:PORTOLA VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-277-2107
Mailing Address - Street 1:PO BOX 1918
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-1918
Mailing Address - Country:US
Mailing Address - Phone:530-277-2107
Mailing Address - Fax:
Practice Address - Street 1:157 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-9606
Practice Address - Country:US
Practice Address - Phone:530-832-4218
Practice Address - Fax:530-832-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
CA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0541183OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA50236Medicaid
0541183OtherNCPDP PROVIDER IDENTIFICATION NUMBER