Provider Demographics
NPI:1093218679
Name:KANISKI, KRISTIAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:
Last Name:KANISKI
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 1:2045 S VINEYARD STE 133
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6893
Mailing Address - Country:US
Mailing Address - Phone:480-969-0600
Mailing Address - Fax:480-969-0712
Practice Address - Street 1:2045 S VINEYARD STE 133
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6893
Practice Address - Country:US
Practice Address - Phone:480-969-0600
Practice Address - Fax:480-969-0712
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS012951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS012951OtherSTATE BOARD OF PHARMACY LICENSE