Healthcare Provider Details

I. General information

NPI: 1699727024
Provider Name (Legal Business Name): MICHELLE HERTELL
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PLAVE
ST. LOUIS MO
63110
US

IV. Provider business mailing address

912 LA'CHERIE
BALLWIN MO
63021
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7666
  • Fax: 314-747-9920
Mailing address:
  • Phone: 636-861-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number043750
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: