Provider Demographics
NPI:1629449434
Name:AHSTROM, KRISTEN (RPH)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:AHSTROM
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 1:25073 W SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-1252
Mailing Address - Country:US
Mailing Address - Phone:623-215-1113
Mailing Address - Fax:623-215-1119
Practice Address - Street 1:25073 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-1252
Practice Address - Country:US
Practice Address - Phone:623-215-1113
Practice Address - Fax:623-215-1119
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS009135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist