Provider Demographics
NPI:1629720339
Name:WITHROW, KRISTY ANN
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:ANN
Last Name:WITHROW
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 1:1462 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1632
Mailing Address - Country:US
Mailing Address - Phone:517-930-1864
Mailing Address - Fax:
Practice Address - Street 1:1462 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1632
Practice Address - Country:US
Practice Address - Phone:517-930-1864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302031351OtherPHARMACIST LICENSE