Provider Demographics
NPI:1942929823
Name:KRUISSELBRINK, MACI
Entity Type:Individual
Prefix:
First Name:MACI
Middle Name:
Last Name:KRUISSELBRINK
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 1:2622 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SLAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:56172-1312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2622 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SLAYTON
Practice Address - State:MN
Practice Address - Zip Code:56172-1312
Practice Address - Country:US
Practice Address - Phone:507-836-6702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist