Provider Demographics
NPI:1841567641
Name:MISTALSKI, LAURA M
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:M
Last Name:MISTALSKI
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 1:47100 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5023
Mailing Address - Country:US
Mailing Address - Phone:586-532-8161
Mailing Address - Fax:
Practice Address - Street 1:47100 HAYES RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5023
Practice Address - Country:US
Practice Address - Phone:586-532-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033133183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist