Provider Demographics
NPI:1073721015
Name:BRASWELL, MICHELLE EDMUNDS
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:EDMUNDS
Last Name:BRASWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WATERFORD WAY
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36312-5492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1023
Practice Address - Country:US
Practice Address - Phone:334-793-1316
Practice Address - Fax:334-793-4920
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL12727OtherAL BOARD OF PHARMACY LIC