Provider Demographics
NPI:1306264817
Name:CRISCIO, MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CRISCIO
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 1:1300 W INTERNATIONAL SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1490
Mailing Address - Country:US
Mailing Address - Phone:386-252-9659
Mailing Address - Fax:386-252-1754
Practice Address - Street 1:1300 W INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1490
Practice Address - Country:US
Practice Address - Phone:386-252-9659
Practice Address - Fax:386-252-1754
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist