Provider Demographics
NPI:1588084305
Name:KOSTARIDES, MICHAEL ANGELO (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANGELO
Last Name:KOSTARIDES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8990 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-1127
Mailing Address - Country:US
Mailing Address - Phone:401-256-1354
Mailing Address - Fax:
Practice Address - Street 1:8990 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-1127
Practice Address - Country:US
Practice Address - Phone:800-379-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI04570183500000X
MA27416183500000X
FL48451183500000X
AZS018790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist