Provider Demographics
NPI:1407476260
Name:COLUSO, KARISSA AIRA TISMO
Entity Type:Individual
Prefix:
First Name:KARISSA AIRA
Middle Name:TISMO
Last Name:COLUSO
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 1:2700 CENTRAL FWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76306-2843
Mailing Address - Country:US
Mailing Address - Phone:940-855-2374
Mailing Address - Fax:
Practice Address - Street 1:2700 CENTRAL FWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76306-2843
Practice Address - Country:US
Practice Address - Phone:940-855-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX66112OtherTEXAS BOARD OF PHARMACY