Provider Demographics
NPI:1104442755
Name:STUNKARD, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:STUNKARD
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 1:1499 LINCOLN CIR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1884
Mailing Address - Country:US
Mailing Address - Phone:406-546-0435
Mailing Address - Fax:
Practice Address - Street 1:1041 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-4302
Practice Address - Country:US
Practice Address - Phone:303-772-1111
Practice Address - Fax:303-772-4247
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25727918183500000X
IN26028248A183500000X
COPHA.0023738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist