MEDICARE: ROBERT W MICKELSON

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	P5300	ID

General Provider Information

NPI Number	:	1205135498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT W MICKELSON

Provider Business Mailing Address
First Line	:	16122 HORIZON DR
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83607-8298
Country	:	US
Telephone Number	:	208-454-8890
Fax Number	:

Provider Business Practice Location Address
First Line	:	2809 CLEVELAND BLVD
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4443
Country	:	US
Telephone Number	:	208-455-1094
Fax Number	:	208-455-1097

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

Provider Enumeration Date	:	03/28/2011
Last Update Date	:	03/28/2011

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Directions to “ ROBERT W MICKELSON ” Practice Location

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