Provider Demographics
NPI:1922600162
Name:GILLOOLY, KIERSTYN THEA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KIERSTYN
Middle Name:THEA
Last Name:GILLOOLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:KIERSTYN
Other - Middle Name:THEA
Other - Last Name:FORNOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6635 STATE ROAD O
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-6362
Mailing Address - Country:US
Mailing Address - Phone:573-220-4459
Mailing Address - Fax:
Practice Address - Street 1:3721 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6102
Practice Address - Country:US
Practice Address - Phone:573-634-2628
Practice Address - Fax:573-635-1768
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist