Provider Demographics
NPI:1477150480
Name:GRAHAM, MIKELLA
Entity Type:Individual
Prefix:
First Name:MIKELLA
Middle Name:
Last Name:GRAHAM
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 1:3018 SHAWVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:PA
Mailing Address - Zip Code:16881-8700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3018 SHAWVILLE HWY
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:PA
Practice Address - Zip Code:16881-8700
Practice Address - Country:US
Practice Address - Phone:814-592-8062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP452662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist