Provider Demographics
NPI:1770889883
Name:DESELMS, KIRSTIN JO (PHARM D)
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:JO
Last Name:DESELMS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20330
Mailing Address - Street 2:MBM
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7033
Mailing Address - Country:US
Mailing Address - Phone:307-433-3694
Mailing Address - Fax:
Practice Address - Street 1:5353 YELLOWSTONE RD
Practice Address - Street 2:MBM
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4178
Practice Address - Country:US
Practice Address - Phone:307-433-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist