Healthcare Provider Details

I. General information

NPI: 1265662027
Provider Name (Legal Business Name): KRISTIN CAMPBELL MAHAN PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 BELLEVUE AVE STE 300
SAINT LOUIS MO
63117-1857
US

IV. Provider business mailing address

1031 BELLEVUE AVE STE 300
SAINT LOUIS MO
63117-1818
US

V. Phone/Fax

Practice location:
  • Phone: 314-646-4225
  • Fax:
Mailing address:
  • Phone: 314-560-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number1-14405
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number2009016877
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: