Provider Demographics
NPI:1750033791
Name:MCNULTY, MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCNULTY
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 1:27624 121ST ST NW
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-9574
Mailing Address - Country:US
Mailing Address - Phone:612-709-4775
Mailing Address - Fax:
Practice Address - Street 1:27624 121ST ST NW
Practice Address - Street 2:
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-9574
Practice Address - Country:US
Practice Address - Phone:612-709-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116328OtherPHARMACIST LICENSE