Provider Demographics
NPI:1740529361
Name:SIDERS, KIRBY
Entity type:Individual
Prefix:
First Name:KIRBY
Middle Name:
Last Name:SIDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:IN
Mailing Address - Zip Code:47920-9791
Mailing Address - Country:US
Mailing Address - Phone:765-490-1474
Mailing Address - Fax:
Practice Address - Street 1:1000 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1446
Practice Address - Country:US
Practice Address - Phone:765-497-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019092A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist