Provider Demographics
NPI:1689956344
Name:PALMER, MICHAEL A (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:PALMER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10415 N TRAILS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8833
Mailing Address - Country:US
Mailing Address - Phone:309-243-2369
Mailing Address - Fax:
Practice Address - Street 1:7815 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2078
Practice Address - Country:US
Practice Address - Phone:309-691-5514
Practice Address - Fax:309-691-5639
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-288141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist