Provider Demographics
NPI:1932709128
Name:VAN GERVEN, MICHELLE (PHARM D)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VAN GERVEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3153 CLAYVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-8662
Mailing Address - Country:US
Mailing Address - Phone:540-529-7682
Mailing Address - Fax:540-527-2363
Practice Address - Street 1:1455 TOWNE SQUARE BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1612
Practice Address - Country:US
Practice Address - Phone:540-527-2364
Practice Address - Fax:540-527-2363
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202203587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist