Provider Demographics
NPI:1265716831
Name:GILLIAM, MICHAEL S (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:S
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OLDE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8714
Mailing Address - Country:US
Mailing Address - Phone:859-223-4207
Mailing Address - Fax:
Practice Address - Street 1:1 OLDE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8714
Practice Address - Country:US
Practice Address - Phone:859-223-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY09989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist