Provider Demographics
NPI:1275256745
Name:KOLL, MICHELLE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KOLL
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 1:8639 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3505
Mailing Address - Country:US
Mailing Address - Phone:773-284-6332
Mailing Address - Fax:
Practice Address - Street 1:8639 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3505
Practice Address - Country:US
Practice Address - Phone:773-284-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist