Provider Demographics
NPI:1750659579
Name:WICHLINSKI, MICHAEL T (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:WICHLINSKI
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-763-8951
Practice Address - Street 1:3564 SCOTTSDALE ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5420
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-763-8951
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015573A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist