Provider Demographics
NPI:1104148246
Name:MISCEDRA, MICHELLE (RPH)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:MISCEDRA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-2013
Mailing Address - Country:US
Mailing Address - Phone:845-229-0407
Mailing Address - Fax:
Practice Address - Street 1:635 DUTCHESS TPKE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-1920
Practice Address - Country:US
Practice Address - Phone:845-471-6130
Practice Address - Fax:845-473-5564
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist