Provider Demographics
NPI:1124424254
Name:FERGUSON, KRYSTLE (PHARMD)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:FERGUSON
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 1:12926 PINERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1038
Mailing Address - Country:US
Mailing Address - Phone:231-838-7937
Mailing Address - Fax:
Practice Address - Street 1:1290 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-8340
Practice Address - Country:US
Practice Address - Phone:989-732-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039409183500000X
MEPR12825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist