Provider Demographics
NPI:1801548755
Name:MATTINGLY, MICHELLE BOUDREAU
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BOUDREAU
Last Name:MATTINGLY
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 1:6545 A C BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-9511
Mailing Address - Country:US
Mailing Address - Phone:607-426-5001
Mailing Address - Fax:
Practice Address - Street 1:715 BONITA DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4603
Practice Address - Country:US
Practice Address - Phone:601-286-6035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-16401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty