Provider Demographics
NPI:1255667986
Name:SISWANTO, EMILY (PHARMD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SISWANTO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18207 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-4902
Mailing Address - Country:US
Mailing Address - Phone:972-307-7556
Mailing Address - Fax:972-307-0735
Practice Address - Street 1:18207 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-4902
Practice Address - Country:US
Practice Address - Phone:972-307-7556
Practice Address - Fax:972-307-0735
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist