Provider Demographics
NPI:1174136378
Name:SMITH, VICTORIA KRYSTEN
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:KRYSTEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-5152
Mailing Address - Country:US
Mailing Address - Phone:417-485-0762
Mailing Address - Fax:
Practice Address - Street 1:1675 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-5152
Practice Address - Country:US
Practice Address - Phone:417-485-0762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018027959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist