Provider Demographics
NPI:1437988664
Name:HERRERA, KRISTYN MARIE
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:MARIE
Last Name:HERRERA
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 1:4300 W 105TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2533
Mailing Address - Country:US
Mailing Address - Phone:219-629-5073
Mailing Address - Fax:
Practice Address - Street 1:1276 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2757
Practice Address - Country:US
Practice Address - Phone:219-662-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-27
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030796A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist