Provider Demographics
NPI:1255800306
Name:PISSOURIOS, MIKE (RPH)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:PISSOURIOS
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 1:3916 LITTLE EGRET CT
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-2711
Mailing Address - Country:US
Mailing Address - Phone:813-810-5165
Mailing Address - Fax:
Practice Address - Street 1:1420 W WATERS AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-2830
Practice Address - Country:US
Practice Address - Phone:813-443-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0265651835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care