Healthcare Provider Details

I. General information

NPI: 1114575180
Provider Name (Legal Business Name): MICHELLE MARIE TE RONDE MANNY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

W236N3250 WATERSIDE CT
PEWAUKEE WI
53072-4067
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number13371-040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number051287810
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: