Provider Demographics
NPI:1366055576
Name:MAYER, MICHELLE (PHARM D)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MAYER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 SAMANTHA ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 REDBIRD CIR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8785
Practice Address - Country:US
Practice Address - Phone:920-351-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15516-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist