Provider Demographics
NPI:1336576891
Name:SU, MICHELLE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:SU
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 1:7 JEFFREY LN
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1607
Mailing Address - Country:US
Mailing Address - Phone:347-534-7842
Mailing Address - Fax:
Practice Address - Street 1:7559 263RD ST
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1150
Practice Address - Country:US
Practice Address - Phone:718-470-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist