Provider Demographics
NPI:1396910493
Name:BIBBO, KATHLEEN (RPH)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:BIBBO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 MIRON LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1566
Mailing Address - Country:US
Mailing Address - Phone:845-336-7833
Mailing Address - Fax:845-382-1102
Practice Address - Street 1:801 MIRON LN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1566
Practice Address - Country:US
Practice Address - Phone:845-336-7833
Practice Address - Fax:845-382-1102
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00524992Medicaid