Provider Demographics
NPI:1144511429
Name:MIKOLOSKO, LORI MARIE
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:MARIE
Last Name:MIKOLOSKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 CIDER RUN RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-6016
Mailing Address - Country:US
Mailing Address - Phone:570-333-0516
Mailing Address - Fax:
Practice Address - Street 1:120 LAUREL PLZ
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3546
Practice Address - Country:US
Practice Address - Phone:570-655-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041521L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist