Provider Demographics
NPI:1336231711
Name:VERDUGO, MICHAEL JESSE (PHARMD, MS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JESSE
Last Name:VERDUGO
Suffix:
Gender:M
Credentials:PHARMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 HAYBINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH JUNCTION
Mailing Address - State:WV
Mailing Address - Zip Code:25442
Mailing Address - Country:US
Mailing Address - Phone:520-440-6396
Mailing Address - Fax:
Practice Address - Street 1:283 HAYBINE DRIVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH JUNCTION
Practice Address - State:WV
Practice Address - Zip Code:25442
Practice Address - Country:US
Practice Address - Phone:520-440-6396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-15283101YA0400X
MN119588183500000X
WV6179183500000X
AZ12494183500000X
CA51262183500000X
CAAPH-101471835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN119588OtherPHARMACIST LICENSE
CAAPH-10147OtherADVANCED PRACTICE PHARMACIST LICENSE
AZ12494OtherPHARMACIST LICENSE
WV6179OtherPHARMACIST LICENSE
AZLASAC-15283OtherASSOCIATE SUBSTANCE ABUSE COUNSELOR
MN474690000Medicaid
CA51262OtherPHARMACIST LICENSE