Provider Demographics
NPI:1245832849
Name:DELUCENAY, MICHAEL GLEN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GLEN
Last Name:DELUCENAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8105 E NORTH RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-7500
Mailing Address - Country:US
Mailing Address - Phone:574-528-0548
Mailing Address - Fax:
Practice Address - Street 1:2304 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6421
Practice Address - Country:US
Practice Address - Phone:574-534-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014270A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist