Provider Demographics
NPI:1205135498
Name:MICKELSON, ROBERT W
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MICKELSON
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 1:16122 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-8298
Mailing Address - Country:US
Mailing Address - Phone:208-454-8890
Mailing Address - Fax:
Practice Address - Street 1:2809 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4443
Practice Address - Country:US
Practice Address - Phone:208-455-1094
Practice Address - Fax:208-455-1097
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist