Provider Demographics
NPI:1699076513
Name:OLDENBORG, MICHELLE (PHARMACY D)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:OLDENBORG
Suffix:
Gender:F
Credentials:PHARMACY D
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ULIBARRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PSC 477
Mailing Address - Street 2:BOX 150
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 477
Practice Address - Street 2:BOX 150
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96306
Practice Address - Country:US
Practice Address - Phone:505-672-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist