Provider Demographics
NPI:1174908255
Name:HUMPHREY, MICHAEL G (PHARM D)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8939 COUNTY LANE 213
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-7202
Mailing Address - Country:US
Mailing Address - Phone:417-680-2025
Mailing Address - Fax:417-680-2026
Practice Address - Street 1:8939 COUNTY LANE 213
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-7202
Practice Address - Country:US
Practice Address - Phone:417-680-2025
Practice Address - Fax:417-680-2026
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS115457183500000X
MO211032453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist