MEDICARE: MR. MICHAEL DIMENNA R.PH.

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	8535	NC

General Provider Information

NPI Number	:	1386789451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL DIMENNA R.PH.

Provider Business Mailing Address
First Line	:	1555 NC HIGHWAY 9
Second Line	:
City	:	BLACK MOUNTAIN
State	:	NC
Zip	:	28711-9685
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	66 RETTA RD
Second Line	:
City	:	FAIRVIEW
State	:	NC
Zip	:	28730-8767
Country	:	US
Telephone Number	:	828-628-3675
Fax Number	:

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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