Provider Demographics
NPI:1013317189
Name:WITTENMYER, MICHELLE RENEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:WITTENMYER
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 1:6605 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS DE ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107
Mailing Address - Country:US
Mailing Address - Phone:505-345-9059
Mailing Address - Fax:
Practice Address - Street 1:315 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3715
Practice Address - Country:US
Practice Address - Phone:505-861-1762
Practice Address - Fax:505-864-6998
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist