Healthcare Provider Details

I. General information

NPI: 1508779562
Provider Name (Legal Business Name): MICHAEL THIEFAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N FLAMINGO RD
PEMBROKE PINES FL
33028-1006
US

IV. Provider business mailing address

4793 VIA BARI APT 7301
LAKE WORTH FL
33463-6815
US

V. Phone/Fax

Practice location:
  • Phone: 954-843-9000
  • Fax:
Mailing address:
  • Phone: 954-843-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License NumberPS64174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: