Provider Demographics
NPI:1346880119
Name:DESROSIER, KAYLYN CASEBOLT (PHARMD)
Entity Type:Individual
Prefix:
First Name:KAYLYN
Middle Name:CASEBOLT
Last Name:DESROSIER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11892 OKEEFE CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8514
Mailing Address - Country:US
Mailing Address - Phone:406-579-8493
Mailing Address - Fax:
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-327-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-39440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist