MEDICARE: DR. KYLE THIELKE PHARMD

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	123246	MN

General Provider Information

NPI Number	:	1700477023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE THIELKE PHARMD

Provider Business Mailing Address
First Line	:	30699 LINCOLN RD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-8083
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	30699 LINCOLN RD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-8083
Country	:	US
Telephone Number	:	651-257-4074
Fax Number	:

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

Provider Enumeration Date	:	01/29/2021
Last Update Date	:	01/29/2021

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