Healthcare Provider Details

I. General information

NPI: 1629690896
Provider Name (Legal Business Name): KYLA CELESTE MITTANCK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 HWY 36
NEEDVILLE TX
77461
US

IV. Provider business mailing address

PO BOX 1030
NEEDVILLE TX
77461-1030
US

V. Phone/Fax

Practice location:
  • Phone: 979-793-5534
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number34832
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: