Provider Demographics
NPI:1770313751
Name:SAMPILO, MICKAYLA
Entity type:Individual
Prefix:
First Name:MICKAYLA
Middle Name:
Last Name:SAMPILO
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 1:22855 E COUNTRY VISTA DR APT 414
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-5020
Mailing Address - Country:US
Mailing Address - Phone:509-863-2819
Mailing Address - Fax:
Practice Address - Street 1:355 E NEIDER AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-3723
Practice Address - Country:US
Practice Address - Phone:208-676-7353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8161471183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist