Provider Demographics
NPI:1255624714
Name:WINDOM, KRISTINA COLIZZI
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:COLIZZI
Last Name:WINDOM
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 1:450 AZALEA SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7321
Mailing Address - Country:US
Mailing Address - Phone:843-871-6935
Mailing Address - Fax:843-871-6935
Practice Address - Street 1:450 AZALEA SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7321
Practice Address - Country:US
Practice Address - Phone:843-871-6935
Practice Address - Fax:843-871-6935
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202010677OtherPHARMACIST LICENSE
SC10938OtherPHARMACIST LICENSE
FLPS 39855OtherPHARMACIST LICENSE