Provider Demographics
NPI:1770170011
Name:MILLER, MAURA
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:
Last Name:MILLER
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 1:158 EAGLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-5492
Mailing Address - Country:US
Mailing Address - Phone:812-675-6544
Mailing Address - Fax:
Practice Address - Street 1:8830 STATE ROAD 60 W
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-7547
Practice Address - Country:US
Practice Address - Phone:812-849-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018279A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist