Provider Demographics
NPI:1043436942
Name:SMITH, MICHAEL J (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:SMITH
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 1:919 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3203
Mailing Address - Country:US
Mailing Address - Phone:603-387-7186
Mailing Address - Fax:
Practice Address - Street 1:11400 JULIANNE AVE N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-9436
Practice Address - Country:US
Practice Address - Phone:612-454-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2206183500000X
MN303094101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No183500000XPharmacy Service ProvidersPharmacist