Healthcare Provider Details

I. General information

NPI: 1659784825
Provider Name (Legal Business Name): RYAN MICKELSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 RIDGE AVE
PHILADELPHIA PA
19128-1642
US

IV. Provider business mailing address

1018 BARTRAM LN
QUAKERTOWN PA
18951-5013
US

V. Phone/Fax

Practice location:
  • Phone: 215-482-1992
  • Fax: 215-482-9146
Mailing address:
  • Phone: 610-762-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP445273
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: