Provider Demographics
NPI:1679946057
Name:CLARK, KYLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:CLARK
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 1:2747 KANSAS DR UNIT 107
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3780 E 15TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8766
Practice Address - Country:US
Practice Address - Phone:970-461-1975
Practice Address - Fax:970-467-4042
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021402183500000X
AL18899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist