Provider Demographics
NPI:1144711383
Name:MIKOVICH, SAMUEL RICHARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:RICHARD
Last Name:MIKOVICH
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 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017024212183500000X
WAPH60836409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist