Provider Demographics
NPI:1518214469
Name:WOLF, PHILLIP JUSTIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JUSTIN
Last Name:WOLF
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1601
Mailing Address - Country:US
Mailing Address - Phone:517-347-4632
Mailing Address - Fax:
Practice Address - Street 1:2131 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1601
Practice Address - Country:US
Practice Address - Phone:517-347-4632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist