Provider Demographics
NPI:1740899988
Name:WILSON, KYLE (PHARMD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WILSON
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 1:1178 HIGHWAY 9 S LOT 2
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38828-9171
Mailing Address - Country:US
Mailing Address - Phone:662-322-2134
Mailing Address - Fax:
Practice Address - Street 1:2013 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3511
Practice Address - Country:US
Practice Address - Phone:662-236-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-166181835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist