Healthcare Provider Details

I. General information

NPI: 1043595176
Provider Name (Legal Business Name): KRISTINE SMOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 E 86TH ST
INDIANAPOLIS IN
46240-2392
US

IV. Provider business mailing address

11683 SHADOWWOOD CT
ZIONSVILLE IN
46077-7806
US

V. Phone/Fax

Practice location:
  • Phone: 317-254-9206
  • Fax:
Mailing address:
  • Phone: 317-733-1343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26020452A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: