Healthcare Provider Details

I. General information

NPI: 1902419856
Provider Name (Legal Business Name): MICAELA ANNE CISSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 DUTCH FORK RD
IRMO SC
29063-8874
US

IV. Provider business mailing address

1504 PIEDMONT PARK RD
TAYLORS SC
29687-2047
US

V. Phone/Fax

Practice location:
  • Phone: 803-781-7877
  • Fax:
Mailing address:
  • Phone: 864-498-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42672
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: