Provider Demographics
NPI:1093255903
Name:DENNIS, MICHELLE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DENNIS
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 1:34 BERGENDAHL DR
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2601
Mailing Address - Country:US
Mailing Address - Phone:860-442-6698
Mailing Address - Fax:
Practice Address - Street 1:34 BERGENDAHL DR
Practice Address - Street 2:
Practice Address - City:GRISWOLD
Practice Address - State:CT
Practice Address - Zip Code:06351-2601
Practice Address - Country:US
Practice Address - Phone:860-442-6698
Practice Address - Fax:860-443-4807
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist