Provider Demographics
NPI:1245585967
Name:CARNEY, KRYSTA
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:
Last Name:CARNEY
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 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492
Mailing Address - Country:US
Mailing Address - Phone:315-768-7470
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-1027
Practice Address - Country:US
Practice Address - Phone:315-768-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY44891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist