Provider Demographics
NPI:1356450126
Name:MABIE, KRISTEN C (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:C
Last Name:MABIE
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 1:2018 UPHOFF RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9319
Mailing Address - Country:US
Mailing Address - Phone:608-839-8381
Mailing Address - Fax:
Practice Address - Street 1:208 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:RIO
Practice Address - State:WI
Practice Address - Zip Code:53960-8015
Practice Address - Country:US
Practice Address - Phone:920-992-3369
Practice Address - Fax:920-992-3371
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33279300Medicaid
WI33279300Medicaid