Healthcare Provider Details

I. General information

NPI: 1851936496
Provider Name (Legal Business Name): MICHELLE LEIGH AUSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HIGHWAY 72 BYP
FREDERICKTOWN MO
63645-7326
US

IV. Provider business mailing address

70 PHEASANT DR
FARMINGTON MO
63640-7655
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-6000
  • Fax:
Mailing address:
  • Phone: 573-664-6991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2019028163
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: