Provider Demographics
NPI:1043682735
Name:MICELLI, MICHAEL (RPH)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MICELLI
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 1:182 NC 102 EAST
Mailing Address - Street 2:
Mailing Address - City:AYDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28513
Mailing Address - Country:US
Mailing Address - Phone:252-746-2699
Mailing Address - Fax:252-746-3164
Practice Address - Street 1:182 NC 102 EAST
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513
Practice Address - Country:US
Practice Address - Phone:252-746-2699
Practice Address - Fax:252-746-3164
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC24333OtherSTATE LICENSE NUMBER