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General NPI Number Information
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NPI Number | 1558179549
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Entity Type | Individual
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Provider Name | KYLE RUSSELL DIBLASI
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Gender | Male
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Dates
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Enumeration Date | 12/21/2024
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Last Update Date | 12/21/2024
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Provider Practice Location Address
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Address Line | 998 WILLIAM D FITCH PKWY
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City | COLLEGE STATION
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State | TX
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Zip | 77845-6452
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Country | US
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Telephone | 979-690-0523
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Fax |
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Provider Business Mailing Address
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Address Line | 1545 ARRINGTON RD APT 1222
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City | COLLEGE STATION
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State | TX
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Zip | 77845-8435
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Country | US
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Telephone | 281-630-9850
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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 | 75128
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License Number State | TX
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