Basic Information
| Provider Information | |||||||||
| NPI: | 1295964146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICCIO | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | KC | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARMD, BCACP, CDCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 SUNSET WAY | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890142333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029685582 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3050 E DESERT INN RD STE 116 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891213872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027960660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2009 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 17625 | NV | N | 1835P0018X | 17625 | NV | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.