Provider Demographics
NPI:1710269949
Name:MISCHKE, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MISCHKE
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 1:5353 YELLOWSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4178
Mailing Address - Country:US
Mailing Address - Phone:307-433-3693
Mailing Address - Fax:307-433-3714
Practice Address - Street 1:5353 YELLOWSTONE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4178
Practice Address - Country:US
Practice Address - Phone:307-433-3693
Practice Address - Fax:307-433-3714
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY2744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist