Healthcare Provider Details

I. General information

NPI: 1780053744
Provider Name (Legal Business Name): KYLE SNOWDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GARLAND ST
EVERETT MA
02149-5066
US

IV. Provider business mailing address

4 COMMONWEALTH CT APT 18
BRIGHTON MA
02135-4508
US

V. Phone/Fax

Practice location:
  • Phone: 617-381-7163
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH23590
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: