Provider Demographics
NPI:1104287093
Name:CRISCO, KYLE WAYNE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:WAYNE
Last Name:CRISCO
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 1:101 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:LOCUST
Mailing Address - State:NC
Mailing Address - Zip Code:28097-9723
Mailing Address - Country:US
Mailing Address - Phone:704-888-6650
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST E
Practice Address - Street 2:
Practice Address - City:LOCUST
Practice Address - State:NC
Practice Address - Zip Code:28097-9723
Practice Address - Country:US
Practice Address - Phone:704-888-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25230183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist