Provider Demographics
NPI:1710049259
Name:ATKEISON, MICHAEL L
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:ATKEISON
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 1:1008 MARTINTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-1901
Mailing Address - Country:US
Mailing Address - Phone:662-534-3342
Mailing Address - Fax:
Practice Address - Street 1:186 MAIN ST
Practice Address - Street 2:
Practice Address - City:ECRU
Practice Address - State:MS
Practice Address - Zip Code:38841-9432
Practice Address - Country:US
Practice Address - Phone:662-489-8084
Practice Address - Fax:662-489-8484
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-5752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1303320001Medicare NSC