Provider Demographics
NPI:1730637398
Name:BUSSERT, KYLA
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:BUSSERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 HIGH CLIFFS RD
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-9552
Mailing Address - Country:US
Mailing Address - Phone:937-232-9782
Mailing Address - Fax:
Practice Address - Street 1:5001 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4513
Practice Address - Country:US
Practice Address - Phone:336-659-0391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist