Healthcare Provider Details

I. General information

NPI: 1316604390
Provider Name (Legal Business Name): KYLE REN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730-32 MARKET ST
PHILADELPHIA PA
19106
US

IV. Provider business mailing address

2304 ABERDEEN WAY
MACUNGIE PA
18062-8240
US

V. Phone/Fax

Practice location:
  • Phone: 215-627-6433
  • Fax:
Mailing address:
  • Phone: 484-538-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP456239
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: