Provider Demographics
NPI:1831500586
Name:WADE, KRISTI
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:WADE
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 1:1201 N SERVICE RD E
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2917
Mailing Address - Country:US
Mailing Address - Phone:318-251-0392
Mailing Address - Fax:318-251-1161
Practice Address - Street 1:1201 N SERVICE RD E
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2917
Practice Address - Country:US
Practice Address - Phone:318-251-0392
Practice Address - Fax:318-251-1161
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist