Provider Demographics
NPI:1144575291
Name:DEHAVEN, KRISTIN MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:MARIE
Last Name:DEHAVEN
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 1:2410 N COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3110
Mailing Address - Country:US
Mailing Address - Phone:260-483-5612
Mailing Address - Fax:
Practice Address - Street 1:2410 N COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3110
Practice Address - Country:US
Practice Address - Phone:260-483-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024633A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist