Provider Demographics
NPI:1891375127
Name:PASQUALETTI, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PASQUALETTI
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 1:1520 EISENHOWER AVE
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-8319
Mailing Address - Country:US
Mailing Address - Phone:706-254-7646
Mailing Address - Fax:
Practice Address - Street 1:1520 EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-8319
Practice Address - Country:US
Practice Address - Phone:706-254-7646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist