Provider Demographics
NPI:1023764966
Name:WILLEY, MICHAEL LYNN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LYNN
Last Name:WILLEY
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 1:13430 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-8469
Mailing Address - Country:US
Mailing Address - Phone:214-906-6685
Mailing Address - Fax:
Practice Address - Street 1:4351 E 104TH AVE
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-4451
Practice Address - Country:US
Practice Address - Phone:303-501-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0012584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist