Provider Demographics
NPI:1528939220
Name:ALVIN, KYLE OTIS
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:OTIS
Last Name:ALVIN
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 1:1628 JACKSON WAY NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-0654
Mailing Address - Country:US
Mailing Address - Phone:786-747-5068
Mailing Address - Fax:
Practice Address - Street 1:1140 N HAIRSTON RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-5800
Practice Address - Country:US
Practice Address - Phone:404-292-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0358463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy