Provider Demographics
NPI:1619587326
Name:VELASQUEZ, MICHELLE ANTIONETTE (CPHT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTIONETTE
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 N 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-9456
Mailing Address - Country:US
Mailing Address - Phone:509-457-1628
Mailing Address - Fax:866-257-1398
Practice Address - Street 1:1207 N 40TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-9456
Practice Address - Country:US
Practice Address - Phone:509-457-1628
Practice Address - Fax:866-257-1398
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60051072183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty