Provider Demographics
NPI:1285935700
Name:MICKELSON, CARYN C (PHARMD)
Entity type:Individual
Prefix:
First Name:CARYN
Middle Name:C
Last Name:MICKELSON
Suffix:
Gender:F
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:PO BOX 3190
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0407
Mailing Address - Country:US
Mailing Address - Phone:541-435-7039
Mailing Address - Fax:541-982-5352
Practice Address - Street 1:630 MILUK DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-7728
Practice Address - Country:US
Practice Address - Phone:541-435-7039
Practice Address - Fax:541-982-5352
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0010326183500000X
OR00103261835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist