Healthcare Provider Details

I. General information

NPI: 1063789915
Provider Name (Legal Business Name): MIRIAM ANSONG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GARDINER LN
LOUISVILLE KY
40205-2962
US

IV. Provider business mailing address

7905 WILLIAMSGATE CIR
CRESTWOOD KY
40014-7011
US

V. Phone/Fax

Practice location:
  • Phone: 469-226-6129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051287451
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: