Provider Demographics
NPI:1760778674
Name:MYERS, KIRK WADE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:WADE
Last Name:MYERS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NORTHERN BLVD
Mailing Address - Street 2:LOUDON PLAZA
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1000
Mailing Address - Country:US
Mailing Address - Phone:518-257-7294
Mailing Address - Fax:518-257-7299
Practice Address - Street 1:350 NORTHERN BLVD
Practice Address - Street 2:LOUDON PLAZA
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1000
Practice Address - Country:US
Practice Address - Phone:518-257-7294
Practice Address - Fax:518-257-7299
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02520056Medicaid
NY5119970001Medicare NSC