Provider Demographics
NPI:1851936496
Name:AUSTIN, MICHELLE LEIGH
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:AUSTIN
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 1:70 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7655
Mailing Address - Country:US
Mailing Address - Phone:573-664-6991
Mailing Address - Fax:
Practice Address - Street 1:1025 HIGHWAY 72 BYP
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-7326
Practice Address - Country:US
Practice Address - Phone:573-783-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019028163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist