Provider Demographics
NPI:1295004661
Name:MORTON, MICHAEL CRAIG
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:MORTON
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 1:215 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1511
Mailing Address - Country:US
Mailing Address - Phone:618-548-0070
Mailing Address - Fax:618-548-9846
Practice Address - Street 1:215 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1511
Practice Address - Country:US
Practice Address - Phone:618-548-0070
Practice Address - Fax:618-548-9846
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist