Provider Demographics
NPI:1033252069
Name:DEWOLF, PHILLIP PRATT (R PH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:PRATT
Last Name:DEWOLF
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11508 SUGAR CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-5011
Mailing Address - Country:US
Mailing Address - Phone:618-262-5673
Mailing Address - Fax:
Practice Address - Street 1:1520 W 9TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2909
Practice Address - Country:US
Practice Address - Phone:618-262-2475
Practice Address - Fax:618-262-2857
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032658183500000X
IN26014009A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist