Provider Demographics
NPI:1083004469
Name:WOOD, MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-4405
Mailing Address - Country:US
Mailing Address - Phone:262-534-9222
Mailing Address - Fax:262-534-9407
Practice Address - Street 1:601 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-4405
Practice Address - Country:US
Practice Address - Phone:262-534-9222
Practice Address - Fax:262-534-9407
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14814-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist