Provider Demographics
NPI:1982972006
Name:MICHAELSEN, ERIC (RPH)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:MICHAELSEN
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 1:3516 274TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-9552
Mailing Address - Country:US
Mailing Address - Phone:319-524-1044
Mailing Address - Fax:
Practice Address - Street 1:1215 MAIN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-4343
Practice Address - Country:US
Practice Address - Phone:319-524-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-03
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist