MEDICARE: MICAH THOMPSON

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	011859	KY

General Provider Information

NPI Number	:	1861772519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAH THOMPSON

Provider Business Mailing Address
First Line	:	3621 FERN VALLEY RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-1916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 FERN VALLEY RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-1916
Country	:	US
Telephone Number	:	502-657-0756
Fax Number	:

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

Provider Enumeration Date	:	08/26/2011
Last Update Date	:	03/01/2023

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