Provider Demographics
NPI:1588352231
Name:VICOSO, MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VICOSO
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 1:6 MOSS CT
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-7484
Mailing Address - Country:US
Mailing Address - Phone:610-248-5177
Mailing Address - Fax:
Practice Address - Street 1:601 S 25TH ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-5336
Practice Address - Country:US
Practice Address - Phone:610-252-7405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP043099L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist