Provider Demographics
NPI:1962582635
Name:KIOLBASA, BRENDA DEE (RP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:DEE
Last Name:KIOLBASA
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32635 ROAD 760
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:NE
Mailing Address - Zip Code:69140-2000
Mailing Address - Country:US
Mailing Address - Phone:308-352-4266
Mailing Address - Fax:308-284-6984
Practice Address - Street 1:23 N SPRUCE ST
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-2548
Practice Address - Country:US
Practice Address - Phone:308-284-4089
Practice Address - Fax:308-284-8964
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist