Provider Demographics
NPI:1629402078
Name:LANCASTER, KYLE C
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:C
Last Name:LANCASTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PETERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127
Mailing Address - Country:US
Mailing Address - Phone:307-654-6337
Mailing Address - Fax:
Practice Address - Street 1:118 PETERSON PKWY
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist