Provider Demographics
NPI:1710494067
Name:KUBATH, ELIJAH JAMES (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:JAMES
Last Name:KUBATH
Suffix:
Gender:M
Credentials:PHARMD
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:269-934-6710
Mailing Address - Fax:
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:269-934-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist