Healthcare Provider Details

I. General information

NPI: 1255829529
Provider Name (Legal Business Name): LUCY PARISH DEWILDT PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12124 W LAKESHORE DR
BRIMLEY MI
49715-9319
US

IV. Provider business mailing address

12124 W LAKESHORE DR
BRIMLEY MI
49715-9319
US

V. Phone/Fax

Practice location:
  • Phone: 906-248-2031
  • Fax: 906-248-8366
Mailing address:
  • Phone: 906-248-2031
  • Fax: 906-248-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302034455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: