Healthcare Provider Details

I. General information

NPI: 1336214758
Provider Name (Legal Business Name): ALICE F TIBBEN R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 LINCOLN WAY
AMES IA
50010-3323
US

IV. Provider business mailing address

720 CHEROKEE ST
NEVADA IA
50201-7972
US

V. Phone/Fax

Practice location:
  • Phone: 515-232-1653
  • Fax: 515-232-3382
Mailing address:
  • Phone: 515-382-8144
  • Fax: 515-232-3382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16615
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: