Provider Demographics
NPI:1790309201
Name:DEMALINE, MICHELLE DIAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DIAN
Last Name:DEMALINE
Suffix:
Gender:F
Credentials:PHARMD
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 1033
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30515-1033
Mailing Address - Country:US
Mailing Address - Phone:770-510-3651
Mailing Address - Fax:
Practice Address - Street 1:2175 PARKLAKE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2845
Practice Address - Country:US
Practice Address - Phone:770-510-3651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0209181835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist