Healthcare Provider Details

I. General information

NPI: 1336695865
Provider Name (Legal Business Name): MICHAEL SHORT PHARM.D., BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEMORIAL MEDICAL CENTER HEART FAILURE CINIC 340 WEST MILLER
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

MEMORIAL MEDICAL CENTER HEART FAILURE CINIC 340 WEST MILLER
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-7491
  • Fax: 217-788-4835
Mailing address:
  • Phone: 217-757-7491
  • Fax: 217-788-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number051.034733
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: