Healthcare Provider Details

I. General information

NPI: 1306350582
Provider Name (Legal Business Name): KYLE SNIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49900 GRAND RIVER AVE
WIXOM MI
48393-3308
US

IV. Provider business mailing address

49900 GRAND RIVER AVE
WIXOM MI
48393-3308
US

V. Phone/Fax

Practice location:
  • Phone: 248-449-8510
  • Fax: 248-449-8565
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302042140
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: