Provider Demographics
NPI:1679963227
Name:WHEATLEY, MICHELLE (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WHEATLEY
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3043
Mailing Address - Country:US
Mailing Address - Phone:208-529-3638
Mailing Address - Fax:
Practice Address - Street 1:1855 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3043
Practice Address - Country:US
Practice Address - Phone:208-529-3638
Practice Address - Fax:208-523-0222
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist