Provider Demographics
NPI:1184921223
Name:WOLZAK, BRAD ALAN
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:ALAN
Last Name:WOLZAK
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 1:4201 S NOLAND RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7313
Mailing Address - Country:US
Mailing Address - Phone:816-478-3088
Mailing Address - Fax:816-478-1623
Practice Address - Street 1:4201 S NOLAND RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-7313
Practice Address - Country:US
Practice Address - Phone:816-478-3088
Practice Address - Fax:816-478-1623
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist