Provider Demographics
NPI:1265011936
Name:WESOLAK, JOHN THOMAS (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:WESOLAK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-1941
Mailing Address - Country:US
Mailing Address - Phone:660-882-6552
Mailing Address - Fax:660-882-9304
Practice Address - Street 1:2150 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1941
Practice Address - Country:US
Practice Address - Phone:660-882-6552
Practice Address - Fax:660-882-9304
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist