Provider Demographics
NPI:1750566147
Name:WOLF, MARK (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WOLF
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 1:5560 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3554
Mailing Address - Country:US
Mailing Address - Phone:718-456-8555
Mailing Address - Fax:
Practice Address - Street 1:5560 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3554
Practice Address - Country:US
Practice Address - Phone:718-456-8555
Practice Address - Fax:718-386-6056
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562481Medicaid