MEDICARE: CHARLES MICHAEL HIGHLEY RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2008027644	MO

General Provider Information

NPI Number	:	1104109842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES MICHAEL HIGHLEY RPH

Provider Business Mailing Address
First Line	:	1930 W GRAND ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-4870
Country	:	US
Telephone Number	:	417-863-6416
Fax Number	:	417-863-1286

Provider Business Practice Location Address
First Line	:	1930 W GRAND ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-4870
Country	:	US
Telephone Number	:	417-863-6416
Fax Number	:	417-863-1286

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	09/20/2011

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