Provider Demographics
NPI:1174684526
Name:WILCOX PHARMACY INC
Entity Type:Organization
Organization Name:WILCOX PHARMACY INC
Other - Org Name:WILCOX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-646-9274
Mailing Address - Street 1:140 EAST RD
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-8705
Mailing Address - Country:US
Mailing Address - Phone:517-646-9274
Mailing Address - Fax:517-646-9278
Practice Address - Street 1:140 EAST RD
Practice Address - Street 2:
Practice Address - City:DIMONDALE
Practice Address - State:MI
Practice Address - Zip Code:48821-8705
Practice Address - Country:US
Practice Address - Phone:517-646-9274
Practice Address - Fax:517-646-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010076273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4503680Medicaid
2043971OtherPK
4760560001Medicare NSC