Provider Demographics
NPI:1063875441
Name:KITILLA, RAHEL
Entity type:Individual
Prefix:
First Name:RAHEL
Middle Name:
Last Name:KITILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 HOFFMAN RD APT 11
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4657
Mailing Address - Country:US
Mailing Address - Phone:612-532-5385
Mailing Address - Fax:
Practice Address - Street 1:245 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4617
Practice Address - Country:US
Practice Address - Phone:651-488-6781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist