Provider Demographics
NPI:1710567276
Name:FUENTES, MICHELLE GUADALUPE (CPHT)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:GUADALUPE
Last Name:FUENTES
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 1:6730 LONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80925-9548
Mailing Address - Country:US
Mailing Address - Phone:719-964-9514
Mailing Address - Fax:
Practice Address - Street 1:6730 LONEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80925-9548
Practice Address - Country:US
Practice Address - Phone:719-964-9514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHAT0000195183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPHAT.0000195OtherCOLORADO STATE BOARD OF PHARMACY