Provider Demographics
NPI:1750098133
Name:MA, KRISTEN RENEE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RENEE
Last Name:MA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15846 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011
Mailing Address - Country:US
Mailing Address - Phone:636-527-6074
Mailing Address - Fax:636-527-6456
Practice Address - Street 1:15846 MANCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-527-6074
Practice Address - Fax:636-527-6456
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110026099183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist