=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811684863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICAELA POMMERENING PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2023
-----------------------------------------------------
Last Update Date | 04/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3050 E AZ 69
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-1113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2905 LEONITA CT
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-7443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | S023115
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------