Provider Demographics
NPI:1699059295
Name:KIES, MICHAEL JOSEPH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:KIES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W JEFFERSON ST
Mailing Address - Street 2:APT 20D
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1378
Mailing Address - Country:US
Mailing Address - Phone:563-599-2152
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2016
Practice Address - Country:US
Practice Address - Phone:309-694-7661
Practice Address - Fax:309-694-8706
Is Sole Proprietor?:No
Enumeration Date:2011-10-01
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist