Provider Demographics
NPI:1417329343
Name:ISHAM, MICHAEL (PHARMD,RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ISHAM
Suffix:
Gender:M
Credentials:PHARMD,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 N DIXIE DOWNS DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-688-7537
Mailing Address - Fax:
Practice Address - Street 1:745 N DIXIE DOWNS DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-688-7537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7725654-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist