Provider Demographics
NPI:1457013385
Name:DECKER, MICHELLE ELAN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELAN
Last Name:DECKER
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 1:909 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3325
Mailing Address - Country:US
Mailing Address - Phone:330-297-7366
Mailing Address - Fax:
Practice Address - Street 1:909 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3325
Practice Address - Country:US
Practice Address - Phone:330-297-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP443995183500000X
OH03129337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist