Provider Demographics
NPI:1821431008
Name:MIKKELSON, M. KRISTA (RPH)
Entity Type:Individual
Prefix:
First Name:M. KRISTA
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 CASE ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-1607
Mailing Address - Country:US
Mailing Address - Phone:860-889-2487
Mailing Address - Fax:
Practice Address - Street 1:112 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2737
Practice Address - Country:US
Practice Address - Phone:860-887-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist