Provider Demographics
NPI:1134715212
Name:MESFUN, MICHAEL (PIC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MESFUN
Suffix:
Gender:M
Credentials:PIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 SAMUELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-6826
Mailing Address - Country:US
Mailing Address - Phone:972-861-5615
Mailing Address - Fax:214-381-1480
Practice Address - Street 1:4645 SAMUELL BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6826
Practice Address - Country:US
Practice Address - Phone:972-861-5615
Practice Address - Fax:214-381-1480
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist