Provider Demographics
NPI:1366851263
Name:CRITCHELOE, MICHAEL JOSEPH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:CRITCHELOE
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 1:530 MID RIVERS MALL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2150
Mailing Address - Country:US
Mailing Address - Phone:636-970-3222
Mailing Address - Fax:
Practice Address - Street 1:530 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2150
Practice Address - Country:US
Practice Address - Phone:636-970-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014026316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist