Provider Demographics
NPI:1598244121
Name:FIOLEK, WALTER J
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:FIOLEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:MANTON
Mailing Address - State:MI
Mailing Address - Zip Code:49663-0601
Mailing Address - Country:US
Mailing Address - Phone:231-884-3904
Mailing Address - Fax:
Practice Address - Street 1:950 EDELWEISS VLG PKWY
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-7441
Practice Address - Country:US
Practice Address - Phone:989-732-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINAMedicaid