Healthcare Provider Details

I. General information

NPI: 1922061001
Provider Name (Legal Business Name): KYLE JESSE YORK PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MCCLURG ST
RICHLAND MO
65556-9998
US

IV. Provider business mailing address

4210 STATE ROAD T
STOUTLAND MO
65567-9188
US

V. Phone/Fax

Practice location:
  • Phone: 573-765-3321
  • Fax:
Mailing address:
  • Phone: 417-286-4516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number200172890
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: