Provider Demographics
NPI:1881044550
Name:WURTZ, MIA ROSE
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ROSE
Last Name:WURTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:ROSE
Other - Last Name:DYDEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 S 44TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-2865
Mailing Address - Country:US
Mailing Address - Phone:253-241-6805
Mailing Address - Fax:
Practice Address - Street 1:111 S 44TH ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-2865
Practice Address - Country:US
Practice Address - Phone:253-241-6805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60413879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist