Provider Demographics
NPI:1689266546
Name:GREENAWALT, KRISTEN LEIGH (BS PHARM)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:GREENAWALT
Suffix:
Gender:F
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3489 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45142-9256
Mailing Address - Country:US
Mailing Address - Phone:937-763-3489
Mailing Address - Fax:
Practice Address - Street 1:159 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2238
Practice Address - Country:US
Practice Address - Phone:937-382-0921
Practice Address - Fax:937-382-0923
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-16260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist