Provider Demographics
NPI:1326221284
Name:WIXOM, MICHAEL W (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:WIXOM
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 1:15481 COMMERCIAL RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54138-9677
Mailing Address - Country:US
Mailing Address - Phone:715-276-3646
Mailing Address - Fax:715-276-9568
Practice Address - Street 1:15481 COMMERCIAL RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138-9677
Practice Address - Country:US
Practice Address - Phone:715-276-3646
Practice Address - Fax:715-276-9568
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12282040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist