Provider Demographics
NPI:1407460611
Name:HOUSE, MICHELLE KATHLEEN (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:HOUSE
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 1:11050 MT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-2603
Mailing Address - Country:US
Mailing Address - Phone:315-772-3696
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-2603
Practice Address - Country:US
Practice Address - Phone:315-772-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51371183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist