Provider Demographics
NPI:1932509114
Name:FELLER, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FELLER
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 1:4201 HIGHWAY 71 E
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-7405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 HIGHWAY 71 E
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-7405
Practice Address - Country:US
Practice Address - Phone:512-308-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist