Provider Demographics
NPI:1972111516
Name:LAUBER, MICHELLE ROXANN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROXANN
Last Name:LAUBER
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 1:210 ASCENT CT APT B
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5383
Mailing Address - Country:US
Mailing Address - Phone:208-859-4789
Mailing Address - Fax:
Practice Address - Street 1:210 ASCENT CT APT B
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5383
Practice Address - Country:US
Practice Address - Phone:208-859-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT47940183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician