Provider Demographics
NPI:1699097766
Name:TUCKER, MICHELLE M
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:TUCKER
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 1:1259 ROUTE 332
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-8915
Mailing Address - Country:US
Mailing Address - Phone:585-742-1910
Mailing Address - Fax:585-742-1910
Practice Address - Street 1:1259 ROUTE 332
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-8915
Practice Address - Country:US
Practice Address - Phone:585-742-1910
Practice Address - Fax:585-742-1910
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist