Provider Demographics
NPI:1386251056
Name:MICK, KRISTIN NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:MICK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 W BOCKMAN WAY
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583
Mailing Address - Country:US
Mailing Address - Phone:931-836-3230
Mailing Address - Fax:
Practice Address - Street 1:483 W BOCKMAN WAY
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583
Practice Address - Country:US
Practice Address - Phone:931-836-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist