=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205108016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIPP C TIGER PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2012
-----------------------------------------------------
Last Update Date | 02/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 COPLEY RD
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44320-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-869-5896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 696 TAMARAC TRL
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-331-7562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03230432
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------