Provider Demographics
NPI:1457758013
Name:MITCHELL, MICAELA DIANE
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:DIANE
Last Name:MITCHELL
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:MC 42-01F BUSH OUTPATIENT PHARMACY
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-271-6451
Mailing Address - Fax:570-271-7065
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:MC 42-01F BUSH OUTPATIENT PHARMACY
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822
Practice Address - Country:US
Practice Address - Phone:570-271-6451
Practice Address - Fax:570-271-7065
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056848183500000X
PARP4539241835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist