Provider Demographics
NPI:1376258996
Name:KASTAW, BIANCA
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:KASTAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42450 FLIS DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2858
Mailing Address - Country:US
Mailing Address - Phone:586-243-2439
Mailing Address - Fax:
Practice Address - Street 1:1191 SOUTH BLVD E
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5453
Practice Address - Country:US
Practice Address - Phone:800-456-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist