Provider Demographics
NPI:1972704500
Name:TIBERG, MICHAEL DAVID (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:TIBERG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 HURON ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3029
Mailing Address - Country:US
Mailing Address - Phone:231-946-8603
Mailing Address - Fax:
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:PHARMACY DEPT.
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-935-7469
Practice Address - Fax:231-935-5667
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist