Provider Demographics
NPI:1740955632
Name:DEWALD, KAYLIN RILEE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KAYLIN
Middle Name:RILEE
Last Name:DEWALD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4529
Mailing Address - Country:US
Mailing Address - Phone:580-920-0234
Mailing Address - Fax:
Practice Address - Street 1:3712 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4529
Practice Address - Country:US
Practice Address - Phone:580-920-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist