Provider Demographics
NPI:1558973206
Name:TIPTON, KAYLA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:
Last Name:TIPTON
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 1:1723 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2838
Mailing Address - Country:US
Mailing Address - Phone:217-222-0792
Mailing Address - Fax:
Practice Address - Street 1:1723 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2838
Practice Address - Country:US
Practice Address - Phone:217-222-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020001235183500000X
IL051.302906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist