Provider Demographics
NPI:1558966143
Name:IGLEHEART, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:IGLEHEART
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 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47567-8525
Mailing Address - Country:US
Mailing Address - Phone:812-354-8939
Mailing Address - Fax:812-354-2623
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-8525
Practice Address - Country:US
Practice Address - Phone:812-354-8939
Practice Address - Fax:812-354-2623
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018611A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist