Provider Demographics
NPI:1720759053
Name:DIBBLE, MADISON ELAINE (RPH)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:ELAINE
Last Name:DIBBLE
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 1:2657 CAMARGO DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-5678
Mailing Address - Country:US
Mailing Address - Phone:361-249-3356
Mailing Address - Fax:
Practice Address - Street 1:11100 LEOPARD ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-2612
Practice Address - Country:US
Practice Address - Phone:361-241-0378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist