MEDICARE: DR. ALYSSA MARIE CAVANAUGH PHARMD

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	5302041023	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962929570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALYSSA MARIE CAVANAUGH PHARMD

Provider Business Mailing Address
First Line	:	16738 WINTERS RD
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9143
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 S MAIN ST
Second Line	:
City	:	CHELSEA
State	:	MI
Zip	:	48118-1426
Country	:	US
Telephone Number	:	734-475-1188
Fax Number	:	734-475-1188

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

Provider Enumeration Date	:	08/24/2017
Last Update Date	:	08/24/2017

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