Healthcare Provider Details

I. General information

NPI: 1063613164
Provider Name (Legal Business Name): MICHELLE COUSINEAU RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE
LEBANON NH
03756
US

IV. Provider business mailing address

PO BOX 183
NEW LONDON NH
03257-0183
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5593
  • Fax:
Mailing address:
  • Phone: 603-927-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3157
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: