Provider Demographics
NPI:1578696621
Name:WANLESS, BRIDGET ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:ANN
Last Name:WANLESS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 BAY ST
Mailing Address - Street 2:POBOX 213
Mailing Address - City:UNIONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48767-9700
Mailing Address - Country:US
Mailing Address - Phone:989-453-5208
Mailing Address - Fax:
Practice Address - Street 1:170 N CASEVILLE RD
Practice Address - Street 2:
Practice Address - City:PIGEON
Practice Address - State:MI
Practice Address - Zip Code:48755-9704
Practice Address - Country:US
Practice Address - Phone:989-453-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist