Healthcare Provider Details

I. General information

NPI: 1750918637
Provider Name (Legal Business Name): MICHAEL WYSONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

IV. Provider business mailing address

601 GRA ROY DR
GOSHEN IN
46526-4805
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-5000
  • Fax:
Mailing address:
  • Phone: 574-350-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03438650
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26028777A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: