Provider Demographics
NPI:1023621372
Name:GOFORTH, KYLIE MORGAN
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:MORGAN
Last Name:GOFORTH
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 1:1112 AMBER VISTA LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37914-1200
Mailing Address - Country:US
Mailing Address - Phone:865-409-7384
Mailing Address - Fax:
Practice Address - Street 1:4325 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37914-3602
Practice Address - Country:US
Practice Address - Phone:865-524-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist