Healthcare Provider Details

I. General information

NPI: 1760015382
Provider Name (Legal Business Name): MICAH JAMES THILL PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 CARDINAL LN
HOBART WI
54313-9569
US

IV. Provider business mailing address

464 CARDINAL LN
GREEN BAY WI
54313-9569
US

V. Phone/Fax

Practice location:
  • Phone: 920-661-9355
  • Fax: 920-661-9309
Mailing address:
  • Phone: 920-661-9355
  • Fax: 920-661-9309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18472-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: