Healthcare Provider Details

I. General information

NPI: 1457846297
Provider Name (Legal Business Name): KIRSTEN ELENA WALLSKOG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

6100 W STATE ST APT 321
WAUWATOSA WI
53213-2990
US

V. Phone/Fax

Practice location:
  • Phone: 530-204-4700
  • Fax:
Mailing address:
  • Phone: 812-272-0682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number5302044700
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5302044700
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: