Provider Demographics
NPI:1255617585
Name:CUSACK, ANDREA R
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:CUSACK
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 1:802 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-1002
Mailing Address - Country:US
Mailing Address - Phone:877-855-9777
Mailing Address - Fax:
Practice Address - Street 1:802 4TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1002
Practice Address - Country:US
Practice Address - Phone:877-855-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist