1073721015 NPI number — MICHELLE EDMUNDS BRASWELL

Table of content: MICHELLE EDMUNDS BRASWELL (NPI 1073721015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073721015 NPI number — MICHELLE EDMUNDS BRASWELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRASWELL
Provider First Name:
MICHELLE
Provider Middle Name:
EDMUNDS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073721015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 WATERFORD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHFORD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36312-5492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4119 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36305-1023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-1316
Provider Business Practice Location Address Fax Number:
334-793-4920
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  12727 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12727 . This is a "AL BOARD OF PHARMACY LIC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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