=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770392649
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN MIKAEAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2025
-----------------------------------------------------
Last Update Date | 01/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 176 COLUMBIA TPKE
-----------------------------------------------------
City | FLORHAM PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07932-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-805-7420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2279 CROSSING WAY
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-250-5756
-----------------------------------------------------
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 | 28RI04353600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------