Provider Demographics
NPI:1922639491
Name:KAKISH, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KAKISH
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 1:1589 HASLETT RD
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8424
Mailing Address - Country:US
Mailing Address - Phone:517-339-5832
Mailing Address - Fax:
Practice Address - Street 1:1589 HASLETT RD
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-8424
Practice Address - Country:US
Practice Address - Phone:517-339-5832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302045527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist