Provider Demographics
NPI:1801186457
Name:KUBA, KEITH (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:KUBA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 W BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1607
Mailing Address - Country:US
Mailing Address - Phone:419-636-3344
Mailing Address - Fax:
Practice Address - Street 1:1221 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1543
Practice Address - Country:US
Practice Address - Phone:419-636-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-17
Last Update Date:2011-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03215200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist