Provider Demographics
NPI:1154678860
Name:RODGERS, KRYSTEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:
Last Name:RODGERS
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 1:7378 FAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44215-9812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 N COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1582
Practice Address - Country:US
Practice Address - Phone:330-725-2706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03131983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist