Provider Demographics
NPI:1427348481
Name:POUTAKIDOU, ELENI
Entity type:Individual
Prefix:
First Name:ELENI
Middle Name:
Last Name:POUTAKIDOU
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 1:4179 WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1051
Mailing Address - Country:US
Mailing Address - Phone:231-709-8992
Mailing Address - Fax:
Practice Address - Street 1:4179 WOODROW AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1051
Practice Address - Country:US
Practice Address - Phone:231-709-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038622183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist