Provider Demographics
NPI:1760775175
Name:CARROLL, MARK KRISTAN (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KRISTAN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S CAROL MALONE BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1352
Mailing Address - Country:US
Mailing Address - Phone:606-474-4470
Mailing Address - Fax:
Practice Address - Street 1:100 S CAROL MALONE BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1352
Practice Address - Country:US
Practice Address - Phone:606-474-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist