Healthcare Provider Details

I. General information

NPI: 1730421710
Provider Name (Legal Business Name): MICHAEL J MICKSCH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W RYAN ST
BRILLION WI
54110-1079
US

IV. Provider business mailing address

6428 ARABIAN WAY
TWO RIVERS WI
54241-8970
US

V. Phone/Fax

Practice location:
  • Phone: 920-756-2640
  • Fax: 920-756-9262
Mailing address:
  • Phone: 920-686-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10271
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: