MEDICARE: KISA KISAKYE

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	1835P1200X	Pharmacotherapy Pharmacist	S014292	AZ

General Provider Information

NPI Number	:	1821758269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KISA KISAKYE

Provider Business Mailing Address
First Line	:	4530 W MCLELLAN RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-4211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10727 W OLIVE AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-9202
Country	:	US
Telephone Number	:	623-815-8074
Fax Number	:

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

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	12/27/2021

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Directions to “ KISA KISAKYE ” Practice Location

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