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General NPI Number Information
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NPI Number | 1497395610
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Entity Type | Individual
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Provider Name | STANLEY KYLE CROCKETT
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Gender | Male
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Dates
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Enumeration Date | 01/15/2020
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Last Update Date | 01/15/2020
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Provider Practice Location Address
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Address Line | N84W16889 MENOMONEE AVE STE 1408
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City | MENOMONEE FALLS
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State | WI
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Zip | 53051-2810
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Country | US
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Telephone | 262-251-8500
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Fax |
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Provider Business Mailing Address
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Address Line | N19W5291 PIERCE CT
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City | CEDARBURG
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State | WI
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Zip | 53012-2953
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 19975-40
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License Number State | WI
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