Provider Demographics
NPI:1235205758
Name:DILLON, MICHELE RENA
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENA
Last Name:DILLON
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 1:315 ROYAL BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:LAVALETTE
Mailing Address - State:WV
Mailing Address - Zip Code:25535-9617
Mailing Address - Country:US
Mailing Address - Phone:304-654-2277
Mailing Address - Fax:
Practice Address - Street 1:5170 US ROUTE 60 STE 2800
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2004
Practice Address - Country:US
Practice Address - Phone:304-399-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006110183500000X
KY012671183500000X
OH03126049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist