Provider Demographics
NPI:1780686121
Name:DORMAN, MICHAEL RUSSELL (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RUSSELL
Last Name:DORMAN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15442 CAMPANILE CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-0309
Mailing Address - Country:US
Mailing Address - Phone:225-358-3920
Mailing Address - Fax:225-358-1158
Practice Address - Street 1:5825 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-2408
Practice Address - Country:US
Practice Address - Phone:225-358-3920
Practice Address - Fax:225-358-1158
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist