Provider Demographics
NPI:1750026407
Name:MAERE, KYLE RICHARD
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:RICHARD
Last Name:MAERE
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 1:945 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-1045
Mailing Address - Country:US
Mailing Address - Phone:309-373-4770
Mailing Address - Fax:
Practice Address - Street 1:303 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1843
Practice Address - Country:US
Practice Address - Phone:563-547-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist