Provider Demographics
NPI:1326331018
Name:MICK, DAVID ELIAS (RP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ELIAS
Last Name:MICK
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-0685
Mailing Address - Country:US
Mailing Address - Phone:304-927-0011
Mailing Address - Fax:304-891-2027
Practice Address - Street 1:218 MARKET ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276
Practice Address - Country:US
Practice Address - Phone:304-927-0011
Practice Address - Fax:304-891-2027
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist