Provider Demographics
NPI:1912330580
Name:SARGENT, KYLE MORGAN (PHARMACISTS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MORGAN
Last Name:SARGENT
Suffix:
Gender:M
Credentials:PHARMACISTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 GREAT TEAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9349
Mailing Address - Country:US
Mailing Address - Phone:304-757-8952
Mailing Address - Fax:
Practice Address - Street 1:5450 BIG TYLER RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1146
Practice Address - Country:US
Practice Address - Phone:304-776-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-18
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0009719183500000X
WVIN0007034390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes183500000XPharmacy Service ProvidersPharmacist