Provider Demographics
NPI:1093316382
Name:WOLFGRAMM, LOUIE T (RPH)
Entity Type:Individual
Prefix:
First Name:LOUIE
Middle Name:T
Last Name:WOLFGRAMM
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 1:829 E 700 N
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-3765
Mailing Address - Country:US
Mailing Address - Phone:801-404-3982
Mailing Address - Fax:
Practice Address - Street 1:1313 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5943
Practice Address - Country:US
Practice Address - Phone:801-373-5665
Practice Address - Fax:801-373-5986
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371864-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist