=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265250203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ALAN CARROLL PHARMD, RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2024
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1260 E SR 205
-----------------------------------------------------
City | COLUMBIA CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-248-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 JEFFREY DR
-----------------------------------------------------
City | COLUMBIA CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46725-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-551-8247
-----------------------------------------------------
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 | 26030998A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------