Provider Demographics
NPI:1578344248
Name:WIGHTMAN, KYLE MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MICHAEL
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5251 PARKSIDE DR UNIT A3
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-7522
Mailing Address - Country:US
Mailing Address - Phone:585-905-6833
Mailing Address - Fax:
Practice Address - Street 1:335 PARRISH ST STE 1500
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1728
Practice Address - Country:US
Practice Address - Phone:585-602-0300
Practice Address - Fax:585-396-9034
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070952183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist