Provider Demographics
NPI:1760023071
Name:GRENNAN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GRENNAN
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:NE
Mailing Address - Zip Code:68064-0400
Mailing Address - Country:US
Mailing Address - Phone:402-359-2284
Mailing Address - Fax:
Practice Address - Street 1:123 E GARDINER ST
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:NE
Practice Address - Zip Code:68064-9798
Practice Address - Country:US
Practice Address - Phone:402-359-2284
Practice Address - Fax:402-359-2285
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist