Provider Demographics
NPI:1720273501
Name:WOLGEMUTH, EDWARD A (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:WOLGEMUTH
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 1:9424 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1935
Mailing Address - Country:US
Mailing Address - Phone:708-857-8274
Mailing Address - Fax:708-857-8128
Practice Address - Street 1:9424 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1935
Practice Address - Country:US
Practice Address - Phone:708-857-8274
Practice Address - Fax:708-857-8128
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist