Provider Demographics
NPI:1356431068
Name:MICHELICH, JOHN J (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:MICHELICH
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 1:4312 S CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-9722
Mailing Address - Country:US
Mailing Address - Phone:520-803-0472
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC, RWBAHC
Practice Address - Street 2:2240 WINROW AVE
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6806183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist