Provider Demographics
NPI:1710582705
Name:JENKINS, LYLE RAY
Entity Type:Individual
Prefix:MR
First Name:LYLE
Middle Name:RAY
Last Name:JENKINS
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 1:2340 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-4108
Mailing Address - Country:US
Mailing Address - Phone:765-438-3194
Mailing Address - Fax:
Practice Address - Street 1:2340 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4108
Practice Address - Country:US
Practice Address - Phone:765-438-3194
Practice Address - Fax:765-452-2257
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist