Provider Demographics
NPI:1790568756
Name:KOCHUMUTTOM, MISHELLE JOHNSON (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MISHELLE
Middle Name:JOHNSON
Last Name:KOCHUMUTTOM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 SIR TURQUIN LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5756
Mailing Address - Country:US
Mailing Address - Phone:469-867-1194
Mailing Address - Fax:
Practice Address - Street 1:733 SUN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3535
Practice Address - Country:US
Practice Address - Phone:254-340-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist