Healthcare Provider Details

I. General information

NPI: 1871166827
Provider Name (Legal Business Name): MICHAEL THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E VIENNA ST
CLIO MI
48420-1421
US

IV. Provider business mailing address

100 E VIENNA ST
CLIO MI
48420-1421
US

V. Phone/Fax

Practice location:
  • Phone: 810-687-0800
  • Fax:
Mailing address:
  • Phone: 810-687-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303031979
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: