Provider Demographics
NPI:1942651526
Name:BRANDT, MICHELLE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRANDT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:DIETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:2500 NE NEFF RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6015
Mailing Address - Country:US
Mailing Address - Phone:541-382-4321
Mailing Address - Fax:
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-382-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-25
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR009763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist