Healthcare Provider Details

I. General information

NPI: 1376726836
Provider Name (Legal Business Name): DEMETRA ELIZABETH ANTIMISIARIS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

501 E BROADWAY SUITE 204
LOUISVILLE KY
40202-1785
US

IV. Provider business mailing address

501 E BROADWAY STE 204 UNIV. OF LOUISVILLE:DEPT. OF FAMILY & GERIATRIC MED
LOUISVILLE KY
40202-1785
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-2813
  • Fax: 502-852-0415
Mailing address:
  • Phone: 502-852-2813
  • Fax: 502-852-0415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number013872
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: