Provider Demographics
NPI:1528410545
Name:MCCULLOUGH, KYLIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:MCCULLOUGH
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 1:5952 BLACKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:NINE MILE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99026-4900
Mailing Address - Country:US
Mailing Address - Phone:509-464-3627
Mailing Address - Fax:
Practice Address - Street 1:5952 BLACKSTONE WAY
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026-4900
Practice Address - Country:US
Practice Address - Phone:509-464-3627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-02
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26161183500000X
CO0022122183500000X
WAPH60955618183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1528410545OtherBCBS OF NC