Provider Demographics
NPI:1033722053
Name:WILCOTT, STEPHANIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILCOTT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 BAYNTON AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3757
Mailing Address - Country:US
Mailing Address - Phone:207-332-8267
Mailing Address - Fax:
Practice Address - Street 1:4166 17 MILE RD NE
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-9451
Practice Address - Country:US
Practice Address - Phone:616-696-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist