Provider Demographics
NPI:1659903672
Name:SHOOK, KRISTY DEAN (CPHT)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:DEAN
Last Name:SHOOK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76367-2805
Mailing Address - Country:US
Mailing Address - Phone:940-592-4191
Mailing Address - Fax:
Practice Address - Street 1:120 W PARK AVE
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367-2805
Practice Address - Country:US
Practice Address - Phone:940-592-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103451183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician