Provider Demographics
NPI:1043552839
Name:HOGABOAM, KYLE SHANE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:SHANE
Last Name:HOGABOAM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 EAST MAIN
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344
Mailing Address - Country:US
Mailing Address - Phone:509-994-2142
Mailing Address - Fax:
Practice Address - Street 1:140 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1040
Practice Address - Country:US
Practice Address - Phone:509-994-2142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00040386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist