Basic Information
| Provider Information | |||||||||
| NPI: | 1912040130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SISTARE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4503 JB DENTON RD | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297209179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032839292 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1073 W MEETING ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297202205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032852021 | ||||||||
| FaxNumber: | 8032857990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | 10346 | SC | Y | Pharmacy Service Providers | Pharmacy Technician |
ID Information
| ID | Type | State | Issuer | Description | 10346 | 01 | SC | SC PHAR TECH REGISTRATION | OTHER |