Provider Demographics
NPI:1265036552
Name:MOTTER, KRISTA (RPH)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MOTTER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 SEVAN LAKE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-7233
Mailing Address - Country:US
Mailing Address - Phone:260-438-5671
Mailing Address - Fax:
Practice Address - Street 1:6309 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1425
Practice Address - Country:US
Practice Address - Phone:260-497-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018640A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist