Provider Demographics
NPI:1467117721
Name:EASTRIDGE, MICHAEL DEAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:EASTRIDGE
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 1:361 VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1620
Mailing Address - Country:US
Mailing Address - Phone:270-692-1801
Mailing Address - Fax:
Practice Address - Street 1:361 VALLEY LN
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1620
Practice Address - Country:US
Practice Address - Phone:270-699-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist