Provider Demographics
NPI:1922431758
Name:LONG, KYLE DEAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DEAN
Last Name:LONG
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 1:1106 S BEECH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:724 N 22ND ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2604
Practice Address - Country:US
Practice Address - Phone:816-396-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012022667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist