Healthcare Provider Details

I. General information

NPI: 1427639970
Provider Name (Legal Business Name): KYLIE CARBOL PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 05/12/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 W EXECUTIVE DR
BOISE ID
83713-0803
US

IV. Provider business mailing address

9850 W ST LUKES DR
NAMPA ID
83687-7912
US

V. Phone/Fax

Practice location:
  • Phone: 208-205-7779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8082
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: