Provider Demographics
NPI:1144779984
Name:MIKOLAIZYK, MICHAEL GENE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GENE
Last Name:MIKOLAIZYK
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 1:192 HILLCREST ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9275
Mailing Address - Country:US
Mailing Address - Phone:989-339-0329
Mailing Address - Fax:
Practice Address - Street 1:192 HILLCREST ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-9275
Practice Address - Country:US
Practice Address - Phone:989-339-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist