Provider Demographics
NPI:1639477110
Name:KRSTIC, IVANA (IVANA KRSTIC, RPH)
Entity Type:Individual
Prefix:MS
First Name:IVANA
Middle Name:
Last Name:KRSTIC
Suffix:
Gender:F
Credentials:IVANA KRSTIC, RPH
Other - Prefix:MS
Other - First Name:IVANA
Other - Middle Name:
Other - Last Name:KRSTIC WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IVANA KRSTIC WATSON
Mailing Address - Street 1:3201 DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-2501
Mailing Address - Country:US
Mailing Address - Phone:415-931-6417
Mailing Address - Fax:
Practice Address - Street 1:3201 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-2501
Practice Address - Country:US
Practice Address - Phone:415-931-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist