MEDICARE: RYAN MICKELSON 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	RP445273	PA

General Provider Information

NPI Number	:	1659784825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MICKELSON RPH

Provider Business Mailing Address
First Line	:	1018 BARTRAM LN
Second Line	:
City	:	QUAKERTOWN
State	:	PA
Zip	:	18951-5013
Country	:	US
Telephone Number	:	610-762-2184
Fax Number	:

Provider Business Practice Location Address
First Line	:	5911 RIDGE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1642
Country	:	US
Telephone Number	:	215-482-1992
Fax Number	:	215-482-9146

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

Provider Enumeration Date	:	06/05/2014
Last Update Date	:	06/05/2014

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Directions to “ RYAN MICKELSON RPH” Practice Location

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