Provider Demographics
NPI:1770925984
Name:AGOSTA, MICHAEL ANTHONY SALVATORE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY SALVATORE
Last Name:AGOSTA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 CRESCENT AVE
Mailing Address - Street 2:APT 251
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-7417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:119
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist