Provider Demographics
NPI:1699880039
Name:MYERS, KRISTI JO
Entity type:Individual
Prefix:MS
First Name:KRISTI
Middle Name:JO
Last Name:MYERS
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 2517
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-0517
Mailing Address - Country:US
Mailing Address - Phone:541-826-4414
Mailing Address - Fax:541-826-8366
Practice Address - Street 1:7591 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-1618
Practice Address - Country:US
Practice Address - Phone:541-826-4414
Practice Address - Fax:541-826-8366
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR043229Medicaid
OR043229Medicaid