Provider Demographics
NPI:1740811264
Name:MADSON, KRISTEN MICHELLE (PHARMD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:MADSON
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 1:621 MEMORIAL DR STE 402
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1074
Mailing Address - Country:US
Mailing Address - Phone:744-004-5505
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 402
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1074
Practice Address - Country:US
Practice Address - Phone:574-400-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028421A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist