Provider Demographics
NPI:1487298980
Name:KUBOSKE, KEITH RICHARD (PHARMD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:RICHARD
Last Name:KUBOSKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:R
Other - Last Name:KUBOSKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 NORTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-3961
Mailing Address - Country:US
Mailing Address - Phone:615-334-1523
Mailing Address - Fax:
Practice Address - Street 1:100 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3927
Practice Address - Country:US
Practice Address - Phone:615-334-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79601835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist