Provider Demographics
NPI:1326424045
Name:SMITH, KATY LAURISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:LAURISSA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:LAURISSA
Other - Last Name:HERNDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:10550 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-5104
Mailing Address - Country:US
Mailing Address - Phone:316-448-4257
Mailing Address - Fax:
Practice Address - Street 1:10550 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-5104
Practice Address - Country:US
Practice Address - Phone:316-448-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-14054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist