Provider Demographics
NPI:1023485117
Name:ANDERSON, MICHELLE ANN
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9267 PAULINE ST
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437-1021
Mailing Address - Country:US
Mailing Address - Phone:231-709-8147
Mailing Address - Fax:
Practice Address - Street 1:9267 PAULINE ST
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-1021
Practice Address - Country:US
Practice Address - Phone:231-709-8147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303002404183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5303002404OtherPHARMACY TECH LIMITED LICENSE