Healthcare Provider Details

I. General information

NPI: 1053772640
Provider Name (Legal Business Name): TIFFANY LEANN WIBLE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 PICASSO SQ
BRAMBLETON VA
20148-6513
US

IV. Provider business mailing address

42121 PICASSO SQ
BRAMBLETON VA
20148-6513
US

V. Phone/Fax

Practice location:
  • Phone: 901-331-1512
  • Fax:
Mailing address:
  • Phone: 901-331-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number39231
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202223448
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number81959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: