=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710770185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL KRYSTKOWIAK PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51670 HUNTINGTON RD
-----------------------------------------------------
City | LA PINE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97739-9626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-536-5052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 SW CENTURY DR APT 601
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-917-1850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH-0020505
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------