Provider Demographics
NPI:1013136670
Name:BOTTRELL, KRISTON LYNN (RPH)
Entity Type:Individual
Prefix:MR
First Name:KRISTON
Middle Name:LYNN
Last Name:BOTTRELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1970
Mailing Address - Country:US
Mailing Address - Phone:417-255-8253
Mailing Address - Fax:
Practice Address - Street 1:1100 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2029
Practice Address - Country:US
Practice Address - Phone:417-257-5837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist