Provider Demographics
NPI:1083244032
Name:MCGOVERN, KYLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MCGOVERN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 N SUMMIT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4459
Mailing Address - Country:US
Mailing Address - Phone:262-569-8204
Mailing Address - Fax:262-569-8215
Practice Address - Street 1:1284 N SUMMIT AVE STE 100
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4459
Practice Address - Country:US
Practice Address - Phone:262-569-8204
Practice Address - Fax:262-569-8215
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16909-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist