Provider Demographics
NPI:1508227273
Name:NOLAN, MICHAEL PATRICK (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:NOLAN
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 1:619 TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:USA MEDDAC, RWBAHC
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-17091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist