MEDICARE: ALICE SUSAN KISELYUK PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	66941	CA

General Provider Information

NPI Number	:	1457625329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE SUSAN KISELYUK PHARM.D.

Provider Business Mailing Address
First Line	:	PO BOX 1084
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91614-0084
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 W EMPIRE AVE
Second Line	:	T1362
City	:	BURBANK
State	:	CA
Zip	:	91504-3403
Country	:	US
Telephone Number	:	818-238-0239
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	02/24/2012

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