Healthcare Provider Details

I. General information

NPI: 1619642311
Provider Name (Legal Business Name): MICHAEL BLAKE CANTRELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 LIBERTY RD
WEST LIBERTY KY
41472-2049
US

IV. Provider business mailing address

6570 FLAT FRK
SALYERSVILLE KY
41465-7219
US

V. Phone/Fax

Practice location:
  • Phone: 606-743-3186
  • Fax:
Mailing address:
  • Phone: 937-571-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number020152
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03438427
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: