Provider Demographics
NPI:1669882395
Name:MITIN, PHILIP (RPH)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:MITIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 WHITE OWL WAY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5206
Mailing Address - Country:US
Mailing Address - Phone:517-347-1536
Mailing Address - Fax:517-333-3065
Practice Address - Street 1:1350 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1314
Practice Address - Country:US
Practice Address - Phone:517-332-8851
Practice Address - Fax:517-333-3065
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020224791835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy