Healthcare Provider Details

I. General information

NPI: 1245238831
Provider Name (Legal Business Name): PAUL GLENN MILLER JR. R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19652 LAMPLIGHTER TRL
MACOMB TOWNSHIP MI
48044-2857
US

IV. Provider business mailing address

19652 LAMPLIGHTER TRL
MACOMB TOWNSHIP MI
48044-2857
US

V. Phone/Fax

Practice location:
  • Phone: 586-286-7276
  • Fax: 586-286-7260
Mailing address:
  • Phone: 586-286-7276
  • Fax: 586-286-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302020818
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: