Provider Demographics
NPI:1548670862
Name:WILSON, KRISTAN (PHARMD, BCACP)
Entity type:Individual
Prefix:
First Name:KRISTAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD, BCACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 CASS LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-9331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4901 STATE ROAD 26 E
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4611
Practice Address - Country:US
Practice Address - Phone:765-449-9210
Practice Address - Fax:765-449-9265
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024031A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy