Provider Demographics
NPI:1629696091
Name:DEAN, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DEAN
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 1:124 WOLF CREEK TRL SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35824-3506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1972 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5901
Practice Address - Country:US
Practice Address - Phone:256-593-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-11
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL17345OtherSTATE PHARMACY LICENSE