Provider Demographics
NPI:1366274748
Name:STRANGE, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:STRANGE
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 1:57001 STATE HIGHWAY T
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MO
Mailing Address - Zip Code:63537-4147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:733 GRAND AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3183
Practice Address - Country:US
Practice Address - Phone:573-221-2792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024032934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist