Provider Demographics
NPI:1013520519
Name:MIZIMAKOSKI, STEVAN (RPH)
Entity type:Individual
Prefix:MR
First Name:STEVAN
Middle Name:
Last Name:MIZIMAKOSKI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 W CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5804
Mailing Address - Country:US
Mailing Address - Phone:317-580-0260
Mailing Address - Fax:
Practice Address - Street 1:873 W CARMEL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5804
Practice Address - Country:US
Practice Address - Phone:317-580-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020232A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist