Provider Demographics
NPI:1386789451
Name:DIMENNA, MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:DIMENNA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 NC HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-9685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 RETTA RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NC
Practice Address - Zip Code:28730-8767
Practice Address - Country:US
Practice Address - Phone:828-628-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist