Healthcare Provider Details

I. General information

NPI: 1326908161
Provider Name (Legal Business Name): MRS. KRISTY LEE COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. KRISTY LEE TRIANTAFILLOU

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 GOLF DR
PONTIAC MI
48341-2354
US

IV. Provider business mailing address

21700 NORTHWESTERN HWY STE 900
SOUTHFIELD MI
48075-4908
US

V. Phone/Fax

Practice location:
  • Phone: 855-445-4554
  • Fax:
Mailing address:
  • Phone: 855-455-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303056275TMP
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: