Provider Demographics
NPI:1972092021
Name:PSILOPOULOS, KYLE GREGORY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:GREGORY
Last Name:PSILOPOULOS
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 1:1097 ONNONTIOGA ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-5901
Mailing Address - Country:US
Mailing Address - Phone:530-416-2627
Mailing Address - Fax:
Practice Address - Street 1:1329 US HIGHWAY 395 N
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5391
Practice Address - Country:US
Practice Address - Phone:775-782-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19228183500000X
CA74434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV19228OtherPHARMACIST STATE LICENSE
CA74434OtherPHARMACIST STATE LICENSE