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General NPI Number Information
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NPI Number | 1437480316
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Entity Type | Individual
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Provider Name | RYAN AMOS MICKELSON PHARMD, BCPS
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Gender | Male
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Dates
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Enumeration Date | 01/16/2010
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Last Update Date | 01/16/2010
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Provider Practice Location Address
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Address Line | 3750 CHEMAWA RD NE
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City | SALEM
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State | OR
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Zip | 97305-1119
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Country | US
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Telephone | 503-304-7600
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Fax |
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Provider Business Mailing Address
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Address Line | 245 SW HOOKER ST APT 1
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City | PORTLAND
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State | OR
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Zip | 97201-4774
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Country | US
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Telephone | 608-212-9204
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 15475-040
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH-0011121
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | BCPS 308009953
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License Number State | OR
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