Healthcare Provider Details

I. General information

NPI: 1699113548
Provider Name (Legal Business Name): MICHELLE CUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25401 75TH ST
SALEM WI
53168-9527
US

IV. Provider business mailing address

2851 ACACIA TER
BUFFALO GROVE IL
60089-6634
US

V. Phone/Fax

Practice location:
  • Phone: 262-843-1550
  • Fax:
Mailing address:
  • Phone: 847-634-0498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16954-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: