Provider Demographics
NPI:1346572369
Name:KRULL-GOSS, KRISTA
Entity type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:
Last Name:KRULL-GOSS
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:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0680
Mailing Address - Country:US
Mailing Address - Phone:315-782-1992
Mailing Address - Fax:315-782-3088
Practice Address - Street 1:18969 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-6329
Practice Address - Country:US
Practice Address - Phone:315-782-1992
Practice Address - Fax:315-782-3088
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054208-1183500000X
PARP439364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist