Provider Demographics
NPI:1851677058
Name:HYSO, KLAID (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KLAID
Middle Name:
Last Name:HYSO
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 1:2637 ROYAL VISTA DR NW APT 302
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-1362
Mailing Address - Country:US
Mailing Address - Phone:231-679-2207
Mailing Address - Fax:
Practice Address - Street 1:1391 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1802
Practice Address - Country:US
Practice Address - Phone:231-739-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist