Provider Demographics
NPI:1588073985
Name:KRUCKEMEYER, CARISSA KATHRYN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:KATHRYN
Last Name:KRUCKEMEYER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:CARISSA
Other - Middle Name:KATHRYN
Other - Last Name:CHADWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:10107 RESEARCH BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1909 GRAND AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-4803
Practice Address - Country:US
Practice Address - Phone:936-776-5228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist