Healthcare Provider Details

I. General information

NPI: 1376310433
Provider Name (Legal Business Name): MICHAEL SISSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

1373 E MITCHELL DR
PHOENIX AZ
85014-5160
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax:
Mailing address:
  • Phone: 480-404-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberS021536
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License NumberS021536
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License NumberS021536
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: