Provider Demographics
NPI:1306827233
Name:PETERS, KYLE R (PHARMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:PETERS
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 1:1021 NEBRASKA ST
Mailing Address - Street 2:PO BOX 5410
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1436
Mailing Address - Country:US
Mailing Address - Phone:712-252-2477
Mailing Address - Fax:712-252-5516
Practice Address - Street 1:1021 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1436
Practice Address - Country:US
Practice Address - Phone:712-252-2477
Practice Address - Fax:712-252-5516
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20044208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0092080Medicaid
IA0092080Medicaid