Provider Demographics
NPI:1093006132
Name:LOOMIS, MICHAEL EDWARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:LOOMIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5053
Mailing Address - Country:US
Mailing Address - Phone:401-294-3662
Mailing Address - Fax:401-294-4901
Practice Address - Street 1:63 BROWN ST
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5053
Practice Address - Country:US
Practice Address - Phone:401-294-3662
Practice Address - Fax:401-294-4901
Is Sole Proprietor?:No
Enumeration Date:2011-04-24
Last Update Date:2011-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist