Provider Demographics
NPI:1932709516
Name:PORTWOOD, KRISTA (PHARMD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:PORTWOOD
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 1:3706 DIANN MARIE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-3818
Mailing Address - Country:US
Mailing Address - Phone:502-326-0805
Mailing Address - Fax:502-326-3048
Practice Address - Street 1:3706 DIANN MARIE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-3818
Practice Address - Country:US
Practice Address - Phone:502-326-0805
Practice Address - Fax:502-326-3048
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010970183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist