Provider Demographics
NPI:1689551418
Name:DOCKSTADER, KYRA GRAY
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:GRAY
Last Name:DOCKSTADER
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 1:576 SW 29TH AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-1283
Mailing Address - Country:US
Mailing Address - Phone:801-846-4465
Mailing Address - Fax:
Practice Address - Street 1:2489 DIPLOMAT PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-5422
Practice Address - Country:US
Practice Address - Phone:239-652-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS69397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist