Healthcare Provider Details

I. General information

NPI: 1689951600
Provider Name (Legal Business Name): MRS. KRISSANDRA CONNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 BIG TYLER RD
CROSS LANES WV
25313-1146
US

IV. Provider business mailing address

5450 BIG TYLER RD
CROSS LANES WV
25313-1146
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-5178
  • Fax:
Mailing address:
  • Phone: 304-776-5178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0007513
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: