Provider Demographics
NPI:1497353296
Name:PACK, MICHELLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:7541 N BERWYN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 THEIL ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1448
Practice Address - Country:US
Practice Address - Phone:262-339-4419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16026-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist