Provider Demographics
NPI:1205945987
Name:STALLBOHM, MICHAEL W (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:STALLBOHM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 CHOATE RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03748-3404
Mailing Address - Country:US
Mailing Address - Phone:603-632-7026
Mailing Address - Fax:
Practice Address - Street 1:3 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-1657
Practice Address - Country:US
Practice Address - Phone:603-298-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist