Provider Demographics
NPI:1962066357
Name:MCCOLLUM, KRISTINE EMILY (PHARM D)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:EMILY
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23528 COUNTY ROAD 4
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:CO
Mailing Address - Zip Code:80642-8606
Mailing Address - Country:US
Mailing Address - Phone:303-875-0772
Mailing Address - Fax:
Practice Address - Street 1:60 W BROMLEY LN
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-3026
Practice Address - Country:US
Practice Address - Phone:303-659-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16811Medicaid