Provider Demographics
NPI:1629628342
Name:DICKENS, KYLE THOMAS (RPH,PHARMD,MHA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:THOMAS
Last Name:DICKENS
Suffix:
Gender:M
Credentials:RPH,PHARMD,MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 CASTING ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-4911
Mailing Address - Country:US
Mailing Address - Phone:209-581-8138
Mailing Address - Fax:
Practice Address - Street 1:30 E OAK ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3222
Practice Address - Country:US
Practice Address - Phone:541-451-8020
Practice Address - Fax:541-451-8027
Is Sole Proprietor?:No
Enumeration Date:2019-09-14
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0017457OtherOREGON BOARD OF PHARMACY
WAIR-60672477OtherWASHINGTON STATE DEPARTMENT OF HEALTH