Provider Demographics
NPI:1083988828
Name:MICKELSON, RICHARD (PHARM D)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E PARKS HWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8283
Mailing Address - Country:US
Mailing Address - Phone:907-352-5033
Mailing Address - Fax:907-352-5027
Practice Address - Street 1:1501 E PARKS HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8283
Practice Address - Country:US
Practice Address - Phone:907-352-5033
Practice Address - Fax:907-352-5027
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist