Provider Demographics
NPI:1063297877
Name:WILLIAMSON, TRISTA
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:WILLIAMSON
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 1:224 SCENIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 EDEN PARK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-6005
Practice Address - Country:US
Practice Address - Phone:513-569-9334
Practice Address - Fax:513-852-3035
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015687183500000X
OH03331430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist