Healthcare Provider Details

I. General information

NPI: 1831956432
Provider Name (Legal Business Name): ALISA A MIATSELITSA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MISSOURI FLAT RD
PLACERVILLE CA
95667-6811
US

IV. Provider business mailing address

5145 EMERALD FELL CT
ANTELOPE CA
95843-5940
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-3447
  • Fax:
Mailing address:
  • Phone: 916-832-1460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number89099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: