Provider Demographics
NPI:1689951600
Name:CONNER, KRISSANDRA
Entity Type:Individual
Prefix:MRS
First Name:KRISSANDRA
Middle Name:
Last Name:CONNER
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 1:5450 BIG TYLER RD
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1146
Mailing Address - Country:US
Mailing Address - Phone:304-776-5178
Mailing Address - Fax:
Practice Address - Street 1:5450 BIG TYLER RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1146
Practice Address - Country:US
Practice Address - Phone:304-776-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist