Provider Demographics
NPI:1124657960
Name:SHOUSE, KRISTA JO
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JO
Last Name:SHOUSE
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 1:403 MYERS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2223
Mailing Address - Country:US
Mailing Address - Phone:423-494-4717
Mailing Address - Fax:
Practice Address - Street 1:923 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2768
Practice Address - Country:US
Practice Address - Phone:423-907-1200
Practice Address - Fax:423-907-1492
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist