Healthcare Provider Details

I. General information

NPI: 1093218679
Provider Name (Legal Business Name): KRISTIAN KANISKI PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 S VINEYARD STE 133
MESA AZ
85210-6893
US

IV. Provider business mailing address

2045 S VINEYARD STE 133
MESA AZ
85210-6893
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-0600
  • Fax: 480-969-0712
Mailing address:
  • Phone: 480-969-0600
  • Fax: 480-969-0712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS012951
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: