Provider Demographics
NPI:1801199849
Name:MAHONEY, MICHELLE (RPH)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3876 E PARIS AVE SE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-3974
Mailing Address - Country:US
Mailing Address - Phone:616-977-9700
Mailing Address - Fax:616-855-0937
Practice Address - Street 1:3876 E PARIS AVE SE
Practice Address - Street 2:SUITE 13
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-3974
Practice Address - Country:US
Practice Address - Phone:616-977-9700
Practice Address - Fax:616-855-0937
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302410977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist