Basic Information
| Provider Information | |||||||||
| NPI: | 1770963373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDANIEL | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | RPH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2252 SW 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666043965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852358796 | ||||||||
| FaxNumber: | 7852351939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2252 SW 10TH AVE | ||||||||
| Address2: | STORMONT-VAIL RETAIL PHARMACY | ||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666043965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852358796 | ||||||||
| FaxNumber: | 7852351939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 1-11364 | KS | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 100443290A | 05 | KS | MEDICAID |