Provider Demographics
NPI:1316411960
Name:PAGE, MICHAEL ALAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:PAGE
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 1:5090 FOOTHILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6517
Mailing Address - Country:US
Mailing Address - Phone:916-783-1355
Mailing Address - Fax:916-783-1360
Practice Address - Street 1:5090 FOOTHILLS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6517
Practice Address - Country:US
Practice Address - Phone:916-783-1355
Practice Address - Fax:916-783-1360
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist