Provider Demographics
NPI:1235510108
Name:FOGLE, KIEL LEON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KIEL
Middle Name:LEON
Last Name:FOGLE
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 1:404 N KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6626
Mailing Address - Country:US
Mailing Address - Phone:573-499-6022
Mailing Address - Fax:
Practice Address - Street 1:404 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-499-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53639183500000X
MO201-701-3181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist