Provider Demographics
NPI:1760891378
Name:BENNWITZ, KRISTINA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:BENNWITZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 E TOWNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3732
Mailing Address - Country:US
Mailing Address - Phone:608-242-6862
Mailing Address - Fax:
Practice Address - Street 1:4122 E TOWNE BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3732
Practice Address - Country:US
Practice Address - Phone:608-242-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1756340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist