Provider Demographics
NPI:1750658159
Name:WOLFE, DARYL
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:WOLFE
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 1:1529 GOLF COURSE DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-8728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16405 RIVER RD
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-0613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist