Provider Demographics
NPI:1194115881
Name:AVERY, MYKISHA
Entity type:Individual
Prefix:
First Name:MYKISHA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15922 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-8047
Mailing Address - Country:US
Mailing Address - Phone:301-720-9001
Mailing Address - Fax:
Practice Address - Street 1:15922 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-8047
Practice Address - Country:US
Practice Address - Phone:301-720-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician