Provider Demographics
NPI:1538444252
Name:MILLER, MIKE (PD)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LEPANTO
Mailing Address - State:AR
Mailing Address - Zip Code:72354-2200
Mailing Address - Country:US
Mailing Address - Phone:870-475-2977
Mailing Address - Fax:
Practice Address - Street 1:102 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LEPANTO
Practice Address - State:AR
Practice Address - Zip Code:72354-2200
Practice Address - Country:US
Practice Address - Phone:870-475-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR07613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist