Provider Demographics
NPI:1083699896
Name:COSTA, MICHELLE MARIE (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIE
Last Name:COSTA
Suffix:
Gender:F
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 DENESE CT
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-9481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15240 S HARLAN RD
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-9754
Practice Address - Country:US
Practice Address - Phone:209-858-5787
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist