Provider Demographics
NPI:1760006605
Name:STARK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:STARK
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 1:1641 G50 HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IA
Mailing Address - Zip Code:50240-9501
Mailing Address - Country:US
Mailing Address - Phone:515-664-7056
Mailing Address - Fax:
Practice Address - Street 1:2400 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213-8235
Practice Address - Country:US
Practice Address - Phone:641-342-1662
Practice Address - Fax:641-342-1664
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist