Provider Demographics
NPI:1750983102
Name:MICHALOWSKI, MARK PHILIP (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PHILIP
Last Name:MICHALOWSKI
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 1:790 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-0107
Mailing Address - Country:US
Mailing Address - Phone:207-991-2348
Mailing Address - Fax:207-947-5671
Practice Address - Street 1:653 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3341
Practice Address - Country:US
Practice Address - Phone:207-947-3680
Practice Address - Fax:207-947-5671
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1447368824OtherHANNAFORD