Provider Demographics
NPI:1447847991
Name:NIEDBALSKI, KEVIN ANDREW (PHARMD, BCGP)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANDREW
Last Name:NIEDBALSKI
Suffix:
Gender:M
Credentials:PHARMD, BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 KIMBELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2936
Mailing Address - Country:US
Mailing Address - Phone:573-380-6992
Mailing Address - Fax:
Practice Address - Street 1:2161 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5817
Practice Address - Country:US
Practice Address - Phone:573-380-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150071771835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric