Provider Demographics
NPI:1003321001
Name:NOVAK, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:NOVAK
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 1:3620 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-1141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3620 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-1141
Practice Address - Country:US
Practice Address - Phone:402-228-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist