Provider Demographics
NPI:1760083166
Name:RUSSELL, KYLE A (PHARMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:RUSSELL
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 1:2750 N 7TH ST APT 4121
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2874
Mailing Address - Country:US
Mailing Address - Phone:918-407-9859
Mailing Address - Fax:
Practice Address - Street 1:220 S ST, HWY OK- 97
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063
Practice Address - Country:US
Practice Address - Phone:918-245-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist