Provider Demographics
NPI:1811597131
Name:WIRT, RONALD (RPH)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:WIRT
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 1:3999 ALPINE AVE NW
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8350
Mailing Address - Country:US
Mailing Address - Phone:616-784-1619
Mailing Address - Fax:
Practice Address - Street 1:3999 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-8350
Practice Address - Country:US
Practice Address - Phone:616-784-1619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist