Provider Demographics
NPI:1467936138
Name:MCCANN, MICHAEL R
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MCCANN
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 1:6610 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3354
Mailing Address - Country:US
Mailing Address - Phone:608-354-7093
Mailing Address - Fax:
Practice Address - Street 1:2600 HWY 138
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589
Practice Address - Country:US
Practice Address - Phone:608-873-9262
Practice Address - Fax:608-873-5496
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11028OtherPHARMACIST
1189627OtherNABP