Provider Demographics
NPI:1679841100
Name:LASTOVICA, MICHELLE KRISTINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KRISTINE
Last Name:LASTOVICA
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 1:1400 MEDFIELD RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 EDWARDS MILL RD STE 123
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5370
Practice Address - Country:US
Practice Address - Phone:919-781-2314
Practice Address - Fax:919-786-1326
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist