Provider Demographics
NPI:1083322861
Name:BRAITHWAITE, KYLE DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DAVID
Last Name:BRAITHWAITE
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 1:5860 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1912
Mailing Address - Country:US
Mailing Address - Phone:414-529-3222
Mailing Address - Fax:
Practice Address - Street 1:5860 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1912
Practice Address - Country:US
Practice Address - Phone:414-529-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21482-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist