Healthcare Provider Details

I. General information

NPI: 1548860737
Provider Name (Legal Business Name): KYLE PRESTON LAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N US HIGHWAY 75
DENISON TX
75020-1595
US

IV. Provider business mailing address

401 N US HIGHWAY 75
DENISON TX
75020-1595
US

V. Phone/Fax

Practice location:
  • Phone: 903-465-8035
  • Fax: 903-465-0590
Mailing address:
  • Phone: 903-465-8035
  • Fax: 903-465-0590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number45011
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: