Provider Demographics
NPI:1093110959
Name:INT VELD, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:INT VELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37854-2330
Mailing Address - Country:US
Mailing Address - Phone:865-354-3422
Mailing Address - Fax:865-354-8381
Practice Address - Street 1:103 N GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854-2330
Practice Address - Country:US
Practice Address - Phone:865-354-3422
Practice Address - Fax:865-354-8381
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist