Provider Demographics
NPI:1346862026
Name:MILLER, CLARISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:MILLER
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:PO BOX C021
Mailing Address - Street 2:
Mailing Address - City:TSAILE
Mailing Address - State:AZ
Mailing Address - Zip Code:86556-5048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:TSAILE MEDICAL CENTER INDIAN RTE 64
Practice Address - Street 2:
Practice Address - City:TSAILE
Practice Address - State:AZ
Practice Address - Zip Code:86556
Practice Address - Country:US
Practice Address - Phone:928-724-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS024290OtherARIZONA STATE BOARD OF PHARMACY