Provider Demographics
NPI:1568749026
Name:WALLACE, KRISTIN RENEE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 EVERGREEN PKWY
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7707
Mailing Address - Country:US
Mailing Address - Phone:303-928-8982
Mailing Address - Fax:303-928-8988
Practice Address - Street 1:3510 EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7707
Practice Address - Country:US
Practice Address - Phone:303-928-8982
Practice Address - Fax:303-928-8988
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist