Provider Demographics
NPI:1588967871
Name:MIKOL, JEFFREY T (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:T
Last Name:MIKOL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:770 W PIKE ST
Mailing Address - Street 2:KROGER PHARMACY
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2649
Mailing Address - Country:US
Mailing Address - Phone:304-623-2598
Mailing Address - Fax:304-623-5839
Practice Address - Street 1:770 W PIKE ST
Practice Address - Street 2:KROGER PHARMACY
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2649
Practice Address - Country:US
Practice Address - Phone:304-623-2598
Practice Address - Fax:304-623-5839
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist