Healthcare Provider Details

I. General information

NPI: 1699073965
Provider Name (Legal Business Name): KYLE WILSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 E 1100 N
PENDLETON IN
46064-9400
US

IV. Provider business mailing address

2611 E 1100 N
PENDLETON IN
46064-9400
US

V. Phone/Fax

Practice location:
  • Phone: 765-425-3170
  • Fax:
Mailing address:
  • Phone: 765-425-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26023687A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: