Provider Demographics
NPI:1992820823
Name:SUTHERLAND, MICHAEL DILLON (PHARMD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DILLON
Last Name:SUTHERLAND
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 1:216 PARK AVE NE
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-5110
Mailing Address - Country:US
Mailing Address - Phone:276-328-2782
Mailing Address - Fax:
Practice Address - Street 1:11349 STATE HIGHWAY 1056
Practice Address - Street 2:
Practice Address - City:MCCARR
Practice Address - State:KY
Practice Address - Zip Code:41544
Practice Address - Country:US
Practice Address - Phone:606-427-9007
Practice Address - Fax:606-427-9184
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7920504OtherAETNA PROVIDER NUMBER
VA00V937W01Medicare ID - Type Unspecified
VAU97037Medicare UPIN
VA104367OtherANTHEM PROVIDER NUMBER