Healthcare Provider Details

I. General information

NPI: 1811018013
Provider Name (Legal Business Name): MICHAEL ANDREW SEMON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E BUCYRUS ST
CRESTLINE OH
44827-1502
US

IV. Provider business mailing address

220 E BUCYRUS ST
CRESTLINE OH
44827-1502
US

V. Phone/Fax

Practice location:
  • Phone: 419-683-3502
  • Fax: 419-683-8006
Mailing address:
  • Phone: 419-683-3502
  • Fax: 419-683-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03314344
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: