Provider Demographics
NPI:1801623004
Name:MILLER, TAKOTA BLAISE
Entity type:Individual
Prefix:
First Name:TAKOTA
Middle Name:BLAISE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 SCOUT RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:PA
Mailing Address - Zip Code:16646-8402
Mailing Address - Country:US
Mailing Address - Phone:814-414-5013
Mailing Address - Fax:
Practice Address - Street 1:600 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4802
Practice Address - Country:US
Practice Address - Phone:814-943-0545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP458915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist