MEDICARE: KYLEE VIDRINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	53267	TX

General Provider Information

NPI Number	:	1376186569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLEE VIDRINE

Provider Business Mailing Address
First Line	:	3809 VANDERBILT ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-3523
Country	:	US
Telephone Number	:	832-527-3558
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 N 16TH ST
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-3616
Country	:	US
Telephone Number	:	409-886-1362
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2019
Last Update Date	:	10/21/2019

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Directions to “ KYLEE VIDRINE ” Practice Location

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