Provider Demographics
NPI:1558179549
Name:DIBLASI, KYLE RUSSELL
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RUSSELL
Last Name:DIBLASI
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 1:1545 ARRINGTON RD APT 1222
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8435
Mailing Address - Country:US
Mailing Address - Phone:281-630-9850
Mailing Address - Fax:
Practice Address - Street 1:998 WILLIAM D FITCH PKWY
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6452
Practice Address - Country:US
Practice Address - Phone:979-690-0523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist