Provider Demographics
NPI:1811619059
Name:BAKER, MICHAEL R
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SUGARCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:44681-9381
Mailing Address - Country:US
Mailing Address - Phone:330-852-6033
Mailing Address - Fax:330-852-6207
Practice Address - Street 1:309 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SUGARCREEK
Practice Address - State:OH
Practice Address - Zip Code:44681-9381
Practice Address - Country:US
Practice Address - Phone:330-852-6033
Practice Address - Fax:330-852-6207
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty