Healthcare Provider Details

I. General information

NPI: 1083699896
Provider Name (Legal Business Name): MICHELLE MARIE COSTA DOCTOR OF PHARMACY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15240 S HARLAN RD
LATHROP CA
95330-9754
US

IV. Provider business mailing address

1543 DENESE CT
MANTECA CA
95337-9481
US

V. Phone/Fax

Practice location:
  • Phone: 209-858-5787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number56872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: