Provider Demographics
NPI:1194287631
Name:VAN VLECK, MICHELLE DENISE (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:VAN VLECK
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 1:24044 MORGAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENTOP
Mailing Address - State:MO
Mailing Address - Zip Code:63546-2511
Mailing Address - Country:US
Mailing Address - Phone:319-670-9415
Mailing Address - Fax:
Practice Address - Street 1:24044 MORGAN RD
Practice Address - Street 2:
Practice Address - City:GREENTOP
Practice Address - State:MO
Practice Address - Zip Code:63546-2511
Practice Address - Country:US
Practice Address - Phone:319-670-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0335423174H00000X
MO2014003295183500000X
IL051296719183500000X
MO21755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No174H00000XOther Service ProvidersHealth Educator