Provider Demographics
NPI:1497094387
Name:MICKLEVITZ, BRYAN J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:MICKLEVITZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16690 SWINGLEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-0758
Mailing Address - Country:US
Mailing Address - Phone:636-812-1473
Mailing Address - Fax:
Practice Address - Street 1:16690 SWINGLEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-0758
Practice Address - Country:US
Practice Address - Phone:636-812-1473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006026094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist