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General NPI Number Information
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NPI Number | 1609220094
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Entity Type | Individual
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Provider Name | MISCHA PESICEK
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Gender | Female
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Dates
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Enumeration Date | 04/21/2016
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Last Update Date | 04/21/2016
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Provider Practice Location Address
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Address Line | 2745 AMERICAN LEGION BLVD
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-3185
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Country | US
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Telephone | 208-587-0861
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Fax |
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Provider Business Mailing Address
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Address Line | 6848 STATE ROUTE 14
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City | RAVENNA
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State | OH
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Zip | 44266-9401
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Country | US
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Telephone | 330-221-6543
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | P7417
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 24599
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 55370
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 03333644
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License Number State | OH
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