Provider Demographics
NPI:1972924629
Name:INGRAM, KYLE BRANDON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:BRANDON
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 NAMEOKI RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3710
Mailing Address - Country:US
Mailing Address - Phone:618-451-9490
Mailing Address - Fax:
Practice Address - Street 1:3655 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3710
Practice Address - Country:US
Practice Address - Phone:618-451-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-25
Last Update Date:2013-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051297300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist