Provider Demographics
NPI:1487296562
Name:MCKIBBAN, KRISTEN ANN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:MCKIBBAN
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 1:6609 PECKHAM ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2856
Mailing Address - Country:US
Mailing Address - Phone:515-419-5988
Mailing Address - Fax:
Practice Address - Street 1:1001 OFFICE PARK RD STE 216
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2509
Practice Address - Country:US
Practice Address - Phone:515-419-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20280183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist