Provider Demographics
NPI:1922061001
Name:YORK, KYLE JESSE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JESSE
Last Name:YORK
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 1:4210 STATE ROAD T
Mailing Address - Street 2:
Mailing Address - City:STOUTLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65567-9188
Mailing Address - Country:US
Mailing Address - Phone:417-286-4516
Mailing Address - Fax:
Practice Address - Street 1:104 MCCLURG ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MO
Practice Address - Zip Code:65556-9998
Practice Address - Country:US
Practice Address - Phone:573-765-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200172890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO359248507Medicaid