Healthcare Provider Details

I. General information

NPI: 1861479586
Provider Name (Legal Business Name): ULTRASOURCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 N BRANDON CIR
WICHITA KS
67226-4511
US

IV. Provider business mailing address

2331 N BRANDON CIR
WICHITA KS
67226-4511
US

V. Phone/Fax

Practice location:
  • Phone: 316-630-8170
  • Fax: 316-630-8170
Mailing address:
  • Phone: 316-630-8170
  • Fax: 316-630-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10876
License Number StateKS

VIII. Authorized Official

Name: MRS. JEANINE ANN BRIZENDINE
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 316-630-8170