Provider Demographics
NPI:1649689209
Name:HILLEREN, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HILLEREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 38TH ST NW
Mailing Address - Street 2:UNIT E
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2953
Mailing Address - Country:US
Mailing Address - Phone:701-893-9183
Mailing Address - Fax:
Practice Address - Street 1:706 38TH ST NW
Practice Address - Street 2:UNIT E
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2953
Practice Address - Country:US
Practice Address - Phone:701-893-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH5662183500000X
MN121743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist