Provider Demographics
NPI:1831956432
Name:MIATSELITSA, ALISA A (PHARMD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:A
Last Name:MIATSELITSA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 EMERALD FELL CT
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-5940
Mailing Address - Country:US
Mailing Address - Phone:916-832-1460
Mailing Address - Fax:
Practice Address - Street 1:4300 MISSOURI FLAT RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6811
Practice Address - Country:US
Practice Address - Phone:530-621-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89099183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist