Healthcare Provider Details

I. General information

NPI: 1174684526
Provider Name (Legal Business Name): WILCOX PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 EAST RD
DIMONDALE MI
48821-8705
US

IV. Provider business mailing address

140 EAST RD
DIMONDALE MI
48821-8705
US

V. Phone/Fax

Practice location:
  • Phone: 517-646-9274
  • Fax: 517-646-9278
Mailing address:
  • Phone: 517-646-9274
  • Fax: 517-646-9278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301007627
License Number StateMI

VIII. Authorized Official

Name: STEPHAN WILCOX
Title or Position: PRESIDENT
Credential: RPH
Phone: 517-646-9274