Provider Demographics
NPI:1902171804
Name:KRSTYEN, MARILOU MINER (RPH)
Entity Type:Individual
Prefix:
First Name:MARILOU
Middle Name:MINER
Last Name:KRSTYEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MARILOU
Other - Middle Name:
Other - Last Name:MINER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:3242 FORTUNA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-5614
Mailing Address - Country:US
Mailing Address - Phone:801-273-0851
Mailing Address - Fax:
Practice Address - Street 1:573 W 100 N
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7018
Practice Address - Country:US
Practice Address - Phone:801-299-3968
Practice Address - Fax:801-299-3965
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT147673-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist