Basic Information
| Provider Information | |||||||||
| NPI: | 1487268322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSSIER | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 CEDAR HEAD RD | ||||||||
| Address2: | |||||||||
| City: | SUGARLOAF | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182493518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084935424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 499 WYOMING AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187043602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707143050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP454985 | PA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.