Healthcare Provider Details

I. General information

NPI: 1619691375
Provider Name (Legal Business Name): KYLA RASHELLE WELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N GREER BLVD
PITTSBURG TX
75686-1409
US

IV. Provider business mailing address

843 MAYFIELD DR
BOARDMAN OH
44512-6462
US

V. Phone/Fax

Practice location:
  • Phone: 903-856-3686
  • Fax:
Mailing address:
  • Phone: 330-531-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14238
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03337841
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number37868
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: