Provider Demographics
NPI:1356738033
Name:RICHARDSON, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KRISTA
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2184 VALLEY OAK LN
Mailing Address - Street 2:1077
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-6265
Mailing Address - Country:US
Mailing Address - Phone:530-219-2748
Mailing Address - Fax:
Practice Address - Street 1:2184 VALLEY OAK LN
Practice Address - Street 2:1077
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-6265
Practice Address - Country:US
Practice Address - Phone:530-219-2748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39062183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician