Provider Demographics
NPI:1073137907
Name:CARRIS, MICHELLE SUZANNE (RPH)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:SUZANNE
Last Name:CARRIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 246TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-7859
Mailing Address - Country:US
Mailing Address - Phone:319-721-7027
Mailing Address - Fax:319-462-5742
Practice Address - Street 1:101 115TH ST
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-7976
Practice Address - Country:US
Practice Address - Phone:319-462-4314
Practice Address - Fax:319-462-5742
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist