Provider Demographics
NPI:1992081400
Name:DONAHUE, MICHAEL T (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:DONAHUE
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 1:2011 JONQUIL PL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1517
Mailing Address - Country:US
Mailing Address - Phone:815-977-3322
Mailing Address - Fax:815-977-3322
Practice Address - Street 1:910 BROAD ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6351
Practice Address - Country:US
Practice Address - Phone:608-362-6047
Practice Address - Fax:608-362-6480
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15379-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist