Provider Demographics
NPI:1659690626
Name:TRAN, MICHELLE (PHARMD INTERN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TRAN
Suffix:
Gender:F
Credentials:PHARMD INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LURAY AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5938
Mailing Address - Country:US
Mailing Address - Phone:616-446-7658
Mailing Address - Fax:
Practice Address - Street 1:1401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1562
Practice Address - Country:US
Practice Address - Phone:616-897-9221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist