Provider Demographics
NPI:1104429521
Name:LANZA, MICHELLE J
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:LANZA
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 1:213 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3509
Mailing Address - Country:US
Mailing Address - Phone:631-838-6872
Mailing Address - Fax:
Practice Address - Street 1:632 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1581
Practice Address - Country:US
Practice Address - Phone:973-396-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04075200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist