Provider Demographics
NPI:1215787676
Name:MIKKELSON, MARK (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MIKKELSON
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 1:230 WATERFORD PKWY S
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1219
Mailing Address - Country:US
Mailing Address - Phone:860-271-4630
Mailing Address - Fax:
Practice Address - Street 1:230 WATERFORD PKWY S
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1219
Practice Address - Country:US
Practice Address - Phone:860-271-4360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT57841835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology