Provider Demographics
NPI:1639760622
Name:PRUDEN, KRYSTAL
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:
Last Name:PRUDEN
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 1:27 BESS RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-6012
Mailing Address - Country:US
Mailing Address - Phone:860-874-2203
Mailing Address - Fax:
Practice Address - Street 1:380 PLAINFIELD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1524
Practice Address - Country:US
Practice Address - Phone:413-794-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPTN.0004847183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician