Healthcare Provider Details

I. General information

NPI: 1902451412
Provider Name (Legal Business Name): MICHAEL HARVEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W STATE ST
BOISE ID
83702-4040
US

IV. Provider business mailing address

1617 S RIVERSTONE LN APT 301
BOISE ID
83706-4088
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-8660
  • Fax:
Mailing address:
  • Phone: 920-366-4293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8492
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: