Provider Demographics
NPI:1730421710
Name:MICKSCH, MICHAEL J (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MICKSCH
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 1:6428 ARABIAN WAY
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-8970
Mailing Address - Country:US
Mailing Address - Phone:920-686-3740
Mailing Address - Fax:
Practice Address - Street 1:1010 W RYAN ST
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-1079
Practice Address - Country:US
Practice Address - Phone:920-756-2640
Practice Address - Fax:920-756-9262
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist