Provider Demographics
NPI:1659485639
Name:WANK ENTERPRISES
Entity type:Organization
Organization Name:WANK ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DUYSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-452-9734
Mailing Address - Street 1:2026 BOSTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4162
Mailing Address - Country:US
Mailing Address - Phone:616-452-9734
Mailing Address - Fax:616-452-7255
Practice Address - Street 1:2026 BOSTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4162
Practice Address - Country:US
Practice Address - Phone:616-452-9734
Practice Address - Fax:616-452-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010020513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0850160001Medicaid
2306187OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0850160001Medicare NSC