Healthcare Provider Details

I. General information

NPI: 1073976163
Provider Name (Legal Business Name): KEVIN WITBRODT PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 KIRBY RD
MEMPHIS TN
38119-8209
US

IV. Provider business mailing address

3860 AUSTIN PEAY HWY
MEMPHIS TN
38128-2501
US

V. Phone/Fax

Practice location:
  • Phone: 901-353-1387
  • Fax: 901-353-5974
Mailing address:
  • Phone: 901-383-4847
  • Fax: 901-383-4848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberE13111
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number37562
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: