Provider Demographics
NPI:1659765360
Name:PERCIVAL, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:PERCIVAL
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 1:5955 ZEAMER AVENUE
Mailing Address - Street 2:673D MDG,
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-1928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVENUE
Practice Address - Street 2:673D MDG
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-1928
Practice Address - Country:US
Practice Address - Phone:907-580-1297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist