Healthcare Provider Details

I. General information

NPI: 1568111318
Provider Name (Legal Business Name): KYLA MARIA DICKEY PHARMD.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

417 W VILLAGE LN
BOISE ID
83702-6230
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24547
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: