Provider Demographics
NPI:1326572215
Name:KYRIELYNN LLC
Entity Type:Organization
Organization Name:KYRIELYNN LLC
Other - Org Name:CARSON'S NORTHRIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNWR
Authorized Official - Prefix:
Authorized Official - First Name:GURJOT JOTI
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-926-2002
Mailing Address - Street 1:4923 SECURITY DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-5651
Mailing Address - Country:US
Mailing Address - Phone:937-504-7700
Mailing Address - Fax:937-504-7311
Practice Address - Street 1:4923 SECURITY DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-5651
Practice Address - Country:US
Practice Address - Phone:937-504-7700
Practice Address - Fax:937-504-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0227172003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168744OtherPK