Provider Demographics
NPI:1306508734
Name:KIEFER, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:KIEFER
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 1:5174 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:RAYMONDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78580
Mailing Address - Country:US
Mailing Address - Phone:956-642-7657
Mailing Address - Fax:
Practice Address - Street 1:3570 W ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-4679
Practice Address - Country:US
Practice Address - Phone:956-350-9938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist