Provider Demographics
NPI:1154098218
Name:SPENCER, DYLAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:
Last Name:SPENCER
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 1:100 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1214
Practice Address - Country:US
Practice Address - Phone:859-873-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist