Provider Demographics
NPI:1336535392
Name:BRENNAN, KYLE ROBERT (PHARMD,)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ROBERT
Last Name:BRENNAN
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 1:15025 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4626
Mailing Address - Country:US
Mailing Address - Phone:636-227-9436
Mailing Address - Fax:
Practice Address - Street 1:15025 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4626
Practice Address - Country:US
Practice Address - Phone:636-227-9436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014038939183500000X
IL051.298290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist