Provider Demographics
NPI:1730195306
Name:ETTEL, MICHELLE GERISE-KOOPMEINERS (RPH)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GERISE-KOOPMEINERS
Last Name:ETTEL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 MUSTANG LN
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MN
Mailing Address - Zip Code:56352-1388
Mailing Address - Country:US
Mailing Address - Phone:320-256-5166
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-255-6465
Practice Address - Fax:320-255-6360
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115240-7183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist