Provider Demographics
NPI:1225653991
Name:KAKASULEFF, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:KAKASULEFF
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 1:24516 OVERDORF RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IN
Mailing Address - Zip Code:46034-7707
Mailing Address - Country:US
Mailing Address - Phone:317-908-7260
Mailing Address - Fax:
Practice Address - Street 1:395 WESTFIELD RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1425
Practice Address - Country:US
Practice Address - Phone:317-770-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021701A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist