Provider Demographics
NPI:1528220308
Name:FERGUSON, MICHAEL ANTHONY (PHARM D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-3013
Mailing Address - Country:US
Mailing Address - Phone:229-559-7737
Mailing Address - Fax:
Practice Address - Street 1:1060 LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636
Practice Address - Country:US
Practice Address - Phone:229-559-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist