Provider Demographics
NPI:1649088220
Name:BLUE, MICHELLE LYNN (RPH)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:BLUE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4214 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2030
Mailing Address - Country:US
Mailing Address - Phone:605-391-5678
Mailing Address - Fax:605-355-8565
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2211
Practice Address - Fax:605-355-2565
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4970183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist