Provider Demographics
NPI:1003356569
Name:COLE, MISTY LAREE
Entity Type:Individual
Prefix:MS
First Name:MISTY
Middle Name:LAREE
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:LAREE
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:8766 NAVAJO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2722
Mailing Address - Country:US
Mailing Address - Phone:619-667-8764
Mailing Address - Fax:858-755-5707
Practice Address - Street 1:8766 NAVAJO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-2722
Practice Address - Country:US
Practice Address - Phone:619-667-8764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist