Healthcare Provider Details

I. General information

NPI: 1528073145
Provider Name (Legal Business Name): WAKEFIELD PHARMACY ENTERPRISES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 SUNDAY LAKE ST
WAKEFIELD MI
49968-1338
US

IV. Provider business mailing address

PO BOX 171
WAKEFIELD MI
49968-0171
US

V. Phone/Fax

Practice location:
  • Phone: 906-229-5966
  • Fax: 906-229-5707
Mailing address:
  • Phone: 906-229-5966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301008317
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5301008317
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KATHY ROCCO
Title or Position: OWNER
Credential: RPH
Phone: 906-229-5966