Healthcare Provider Details

I. General information

NPI: 1083601496
Provider Name (Legal Business Name): KIBBLE ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 MAIN ST
QUINCY CA
95971-9120
US

IV. Provider business mailing address

157 COMMERCIAL ST
PORTOLA CA
96122-9606
US

V. Phone/Fax

Practice location:
  • Phone: 530-832-4218
  • Fax: 530-832-1375
Mailing address:
  • Phone: 530-832-4218
  • Fax: 530-283-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY46583
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL KIBBLE
Title or Position: PHARMACIST OWNER
Credential: PHARM D
Phone: 530-283-0480