Provider Demographics
NPI:1023005402
Name:WILLIS, MICHAEL GREGORY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 CLARION DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-1731
Mailing Address - Country:US
Mailing Address - Phone:919-382-7471
Mailing Address - Fax:
Practice Address - Street 1:3643 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2702
Practice Address - Country:US
Practice Address - Phone:919-470-4168
Practice Address - Fax:919-470-7365
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17321183500000X
AZ14200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist