Provider Demographics
NPI:1144602053
Name:WITTLIEFF, SALLY
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:
Last Name:WITTLIEFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W US HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-7612
Mailing Address - Country:US
Mailing Address - Phone:231-845-3764
Mailing Address - Fax:
Practice Address - Street 1:3900 W US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-7612
Practice Address - Country:US
Practice Address - Phone:231-845-3764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020281891835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy