Provider Demographics
NPI:1861479586
Name:ULTRASOURCE, INC.
Entity Type:Organization
Organization Name:ULTRASOURCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRIZENDINE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:316-630-8170
Mailing Address - Street 1:2331 N BRANDON CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-4511
Mailing Address - Country:US
Mailing Address - Phone:316-630-8170
Mailing Address - Fax:316-630-8170
Practice Address - Street 1:2331 N BRANDON CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4511
Practice Address - Country:US
Practice Address - Phone:316-630-8170
Practice Address - Fax:316-630-8170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty