Provider Demographics
NPI:1124180195
Name:COUSINO, AUDREY LYNN (RPH)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:LYNN
Last Name:COUSINO
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 1:15521 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-3954
Mailing Address - Country:US
Mailing Address - Phone:734-243-5656
Mailing Address - Fax:
Practice Address - Street 1:15521 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3954
Practice Address - Country:US
Practice Address - Phone:734-243-5656
Practice Address - Fax:734-457-0037
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist