Provider Demographics
NPI:1003586033
Name:WING, MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WING
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16943 W 68TH ST APT 259
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66217-9670
Mailing Address - Country:US
Mailing Address - Phone:816-853-5741
Mailing Address - Fax:
Practice Address - Street 1:1075 W SANTA FE ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-3115
Practice Address - Country:US
Practice Address - Phone:913-764-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021034107183500000X
KS1-103889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist