Provider Demographics
NPI:1508141896
Name:CARBONNEAU, MICHAEL E (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CARBONNEAU
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S KNISS AVE
Mailing Address - Street 2:
Mailing Address - City:LUVERNE
Mailing Address - State:MN
Mailing Address - Zip Code:56156-1775
Mailing Address - Country:US
Mailing Address - Phone:507-283-9549
Mailing Address - Fax:507-283-9540
Practice Address - Street 1:202 S KNISS AVE
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156-1775
Practice Address - Country:US
Practice Address - Phone:507-283-9549
Practice Address - Fax:507-283-9540
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist