Provider Demographics
NPI:1093076234
Name:KALISIESKI, MATTHEW JONATHAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JONATHAN
Last Name:KALISIESKI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7436 POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2226
Mailing Address - Country:US
Mailing Address - Phone:313-909-8356
Mailing Address - Fax:
Practice Address - Street 1:180 S LILLEY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1400
Practice Address - Country:US
Practice Address - Phone:734-844-0296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist