Provider Demographics
NPI:1699019885
Name:WHEATLEY, KYLE JASON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JASON
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 E NORTH 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-2848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 E NORTH 1ST ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-2848
Practice Address - Country:US
Practice Address - Phone:864-882-9610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist