Provider Demographics
NPI:1629378146
Name:STAAB, KRISTIN G (RPH)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:G
Last Name:STAAB
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 1:3824 BELL MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7710
Mailing Address - Country:US
Mailing Address - Phone:720-839-1954
Mailing Address - Fax:
Practice Address - Street 1:2785 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1360
Practice Address - Country:US
Practice Address - Phone:719-593-8940
Practice Address - Fax:719-598-3918
Is Sole Proprietor?:No
Enumeration Date:2010-10-31
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000171948Medicaid