Provider Demographics
NPI:1336739788
Name:WOLONSAVICH, BRIAN WALTER
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WALTER
Last Name:WOLONSAVICH
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 1:16 FERN ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1570
Mailing Address - Country:US
Mailing Address - Phone:978-927-5084
Mailing Address - Fax:
Practice Address - Street 1:2 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7907
Practice Address - Country:US
Practice Address - Phone:800-552-4449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225231835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist