Provider Demographics
NPI:1841674801
Name:SMITH, MICHAEL THOMAS (PHARMD, BCPS, BCMTMS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHARMD, BCPS, BCMTMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SANIBEL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8618
Mailing Address - Country:US
Mailing Address - Phone:323-457-6484
Mailing Address - Fax:585-210-4197
Practice Address - Street 1:259 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-3632
Practice Address - Country:US
Practice Address - Phone:585-210-4197
Practice Address - Fax:585-210-4197
Is Sole Proprietor?:No
Enumeration Date:2015-07-18
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR3133183500000X
NY060548183500000X, 1835P0018X
VT0330117935183500000X, 1835P0018X, 1835P1200X, 1835P1300X, 1835P2201X
MAPH237023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
14950302OtherCAQH