Provider Demographics
NPI:1225340904
Name:MUTANGADURA, MILCA (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:MILCA
Middle Name:
Last Name:MUTANGADURA
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34279 ASPEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-6105
Mailing Address - Country:US
Mailing Address - Phone:586-725-4199
Mailing Address - Fax:
Practice Address - Street 1:37165 S GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-2315
Practice Address - Country:US
Practice Address - Phone:586-468-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist