Provider Demographics
NPI:1528410545
Name:MCCULLOUGH, KYLIE (PHARMD)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:MCCULLOUGH
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 1:601 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-2510
Mailing Address - Country:US
Mailing Address - Phone:406-454-6973
Mailing Address - Fax:406-791-9277
Practice Address - Street 1:105 6TH ST N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-2531
Practice Address - Country:US
Practice Address - Phone:406-791-7903
Practice Address - Fax:406-791-7998
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-02
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26161183500000X
CO0022122183500000X
WAPH60955618183500000X
MTPHA-PHA-LIC-102497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1528410545OtherBCBS OF NC