MEDICARE: KRISTYN YEMM DISOGRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	28487	NC
2	183500000X	Pharmacist	122267	MN

General Provider Information

NPI Number	:	1871837021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTYN YEMM DISOGRA

Provider Business Mailing Address
First Line	:	PO BOX 356015
Second Line	:	1959 NE PACIFIC STREET
City	:	SEATTLE
State	:	WA
Zip	:	98195
Country	:	US
Telephone Number	:	206-598-6062
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 GOLF ACRES DR STE B1
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-5976
Country	:	US
Telephone Number	:	704-512-6057
Fax Number	:	704-512-6058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2012
Last Update Date	:	07/24/2020

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