Provider Demographics
NPI:1982207445
Name:KOLB, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:KOLB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7079 N AYCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1232
Mailing Address - Country:US
Mailing Address - Phone:309-258-6158
Mailing Address - Fax:
Practice Address - Street 1:4191 THE CIRCLE AT NORTH HILLS ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5712
Practice Address - Country:US
Practice Address - Phone:919-786-2534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty