Provider Demographics
NPI:1780294561
Name:BAILEY, COREY ANDREW
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:ANDREW
Last Name:BAILEY
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 1:8361 PORTLAND AVE UPPR UNIT
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3017
Mailing Address - Country:US
Mailing Address - Phone:915-760-1930
Mailing Address - Fax:
Practice Address - Street 1:3522 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3846
Practice Address - Country:US
Practice Address - Phone:414-342-4446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20437-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist