Provider Demographics
NPI:1699482653
Name:FAIRLEY, KYRA
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2305
Practice Address - Country:US
Practice Address - Phone:315-788-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist