Healthcare Provider Details

I. General information

NPI: 1992422398
Provider Name (Legal Business Name): KRISTY BALDERSON PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTY KB ELLIOTT

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 KINGS CHARTER DR
ASHLAND VA
23005-7994
US

IV. Provider business mailing address

8060 WISTAR GLEN DR
HENRICO VA
23228-3620
US

V. Phone/Fax

Practice location:
  • Phone: 800-753-0596
  • Fax: 804-799-7917
Mailing address:
  • Phone: 804-398-9069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202010664
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: