MEDICARE: KYLE NELSON CLONTS 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	16058	AZ

General Provider Information

NPI Number	:	1922308352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE NELSON CLONTS PHARMD

Provider Business Mailing Address
First Line	:	1255 W BASELINE RD STE 138
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-5821
Country	:	US
Telephone Number	:	480-281-2930
Fax Number	:	480-209-1660

Provider Business Practice Location Address
First Line	:	1255 W BASELINE RD STE 138
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-5821
Country	:	US
Telephone Number	:	480-281-2930
Fax Number	:	480-209-1660

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

Provider Enumeration Date	:	11/02/2010
Last Update Date	:	09/08/2016

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