Provider Demographics
NPI:1528512787
Name:RAES, MICHAELA CAMILLE (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:CAMILLE
Last Name:RAES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:CAMILLE
Other - Last Name:LYSOGORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3495 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1129
Mailing Address - Country:US
Mailing Address - Phone:716-862-9200
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-862-8523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062013183500000X
TX58966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist