Provider Demographics
NPI:1972870970
Name:GRIMSLID, KYLE RYAN (PHARM D, RPH)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:RYAN
Last Name:GRIMSLID
Suffix:
Gender:M
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 HIGHWAY 71 EAST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602
Mailing Address - Country:US
Mailing Address - Phone:512-308-1239
Mailing Address - Fax:512-308-1082
Practice Address - Street 1:4201 HWY71 E
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602
Practice Address - Country:US
Practice Address - Phone:512-308-1239
Practice Address - Fax:512-308-1082
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist