Provider Demographics
NPI:1548796667
Name:DESTA, KAHSU (PHARM D)
Entity Type:Individual
Prefix:
First Name:KAHSU
Middle Name:
Last Name:DESTA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7468
Mailing Address - Country:US
Mailing Address - Phone:910-808-7563
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:910-808-7563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist