Provider Demographics
NPI:1376077792
Name:THEISEN, KRISTIN MARY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARY
Last Name:THEISEN
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 1:12099 BLACKWOOD AVE NW
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-3300
Mailing Address - Country:US
Mailing Address - Phone:320-274-3062
Mailing Address - Fax:320-274-6546
Practice Address - Street 1:12099 BLACKWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-3300
Practice Address - Country:US
Practice Address - Phone:320-274-3062
Practice Address - Fax:320-274-6546
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist