Healthcare Provider Details

I. General information

NPI: 1639701915
Provider Name (Legal Business Name): KAYLA MCCORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 ROMBACH AVE
WILMINGTON OH
45177-1943
US

IV. Provider business mailing address

500 COUNTRY MANOR DR
WILMINGTON OH
45177-7317
US

V. Phone/Fax

Practice location:
  • Phone: 937-655-5720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03232624
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: