MEDICARE: KYLE V BROTHERTON PHARM. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302038806	MI

General Provider Information

NPI Number	:	1669966263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE V BROTHERTON PHARM. D.

Provider Business Mailing Address
First Line	:	415 W VIENNA ST
Second Line	:
City	:	CLIO
State	:	MI
Zip	:	48420-1307
Country	:	US
Telephone Number	:	181-054-7127
Fax Number	:	810-547-1542

Provider Business Practice Location Address
First Line	:	415 W VIENNA ST
Second Line	:
City	:	CLIO
State	:	MI
Zip	:	48420-1307
Country	:	US
Telephone Number	:	181-054-7127
Fax Number	:	810-547-1542

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2018
Last Update Date	:	05/27/2021

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