Provider Demographics
NPI:1568512952
Name:RICHARD, MICHELE R
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:R
Last Name:RICHARD
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 1:5404 LEE FARM BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5453
Mailing Address - Country:US
Mailing Address - Phone:850-398-5063
Mailing Address - Fax:
Practice Address - Street 1:3351 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-8484
Practice Address - Country:US
Practice Address - Phone:850-682-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 40611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist