Provider Demographics
NPI:1962006361
Name:CHRISTENSEN, COLTON
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 FORT JESSE RD
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3489
Mailing Address - Country:US
Mailing Address - Phone:309-452-1370
Mailing Address - Fax:
Practice Address - Street 1:1701 FORT JESSE RD
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3489
Practice Address - Country:US
Practice Address - Phone:309-452-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist