Provider Demographics
NPI:1780029876
Name:EBBERT, MICHAEL JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:EBBERT
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 1:3538 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9054
Mailing Address - Country:US
Mailing Address - Phone:304-212-7207
Mailing Address - Fax:888-808-0795
Practice Address - Street 1:3538 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9054
Practice Address - Country:US
Practice Address - Phone:304-212-7207
Practice Address - Fax:888-808-0795
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004542183500000X
OH03317167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0004542OtherSTATE BOARD OF PHARMACY