=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578372371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE NGUYEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2025
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2245 84TH ST SW
-----------------------------------------------------
City | BYRON CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49315-9174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-878-6047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2245 84TH ST SW
-----------------------------------------------------
City | BYRON CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49315-9174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5351017452
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------