Provider Demographics
NPI:1942800727
Name:DOLAN, MICHAEL ALLAN (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLAN
Last Name:DOLAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:4033 EAGLE WING RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-8092
Mailing Address - Country:US
Mailing Address - Phone:217-502-4548
Mailing Address - Fax:
Practice Address - Street 1:1100 LEJUNE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4537
Practice Address - Country:US
Practice Address - Phone:217-529-6299
Practice Address - Fax:217-529-6326
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.037751183500000X
IL051037751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist