Provider Demographics
NPI:1891279576
Name:SALLAZ, KATHLYN LANDIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATHLYN
Middle Name:LANDIS
Last Name:SALLAZ
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:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-0276
Mailing Address - Country:US
Mailing Address - Phone:304-253-7474
Mailing Address - Fax:304-253-7495
Practice Address - Street 1:1299 ROBERT C BYRD DR.
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827
Practice Address - Country:US
Practice Address - Phone:304-253-7474
Practice Address - Fax:304-253-7495
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1619050754OtherNPI