Provider Demographics
NPI:1447566716
Name:FARAGALLAH, MICHAEL G
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:FARAGALLAH
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 1:377 HILL VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-8214
Mailing Address - Country:US
Mailing Address - Phone:805-651-0102
Mailing Address - Fax:
Practice Address - Street 1:377 HILL VALLEY CT
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-8214
Practice Address - Country:US
Practice Address - Phone:805-651-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 60785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist