Provider Demographics
NPI:1609220094
Name:PESICEK, MISCHA
Entity Type:Individual
Prefix:
First Name:MISCHA
Middle Name:
Last Name:PESICEK
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 1:6848 STATE ROUTE 14
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9401
Mailing Address - Country:US
Mailing Address - Phone:330-221-6543
Mailing Address - Fax:
Practice Address - Street 1:2745 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3185
Practice Address - Country:US
Practice Address - Phone:208-587-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7417183500000X
NC24599183500000X
TX55370183500000X
OH03333644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist