Provider Demographics
NPI:1336813609
Name:WAYNER, KYLE MATTHEW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MATTHEW
Last Name:WAYNER
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 1:609 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2040
Mailing Address - Country:US
Mailing Address - Phone:920-356-1500
Mailing Address - Fax:
Practice Address - Street 1:609 N SPRING ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2040
Practice Address - Country:US
Practice Address - Phone:920-356-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI210211835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist