Provider Demographics
NPI:1093139669
Name:BOYDSTON, KYLE (RPH)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:BOYDSTON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9489
Mailing Address - Country:US
Mailing Address - Phone:575-359-3435
Mailing Address - Fax:575-359-3213
Practice Address - Street 1:1604 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9489
Practice Address - Country:US
Practice Address - Phone:575-359-3435
Practice Address - Fax:575-359-3213
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist