=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205135498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT W MICKELSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2011
-----------------------------------------------------
Last Update Date | 03/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2809 CLEVELAND BLVD
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-4443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-455-1094
-----------------------------------------------------
Fax | 208-455-1097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16122 HORIZON DR
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-8298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-454-8890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P5300
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------