Provider Demographics
NPI:1821559659
Name:DEVINE, KEVIN LYLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LYLE
Last Name:DEVINE
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 1:1223 W BALSAM ST
Mailing Address - Street 2:APT 42
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:360-536-3790
Mailing Address - Fax:
Practice Address - Street 1:200 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1718
Practice Address - Country:US
Practice Address - Phone:509-765-1217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60872061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60872061OtherWASHINGTON STATE DOH