Healthcare Provider Details

I. General information

NPI: 1487240107
Provider Name (Legal Business Name): MICHAEL WYNNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 WALNUT ST
PHILADELPHIA PA
19107-4965
US

IV. Provider business mailing address

1117 WALNUT ST
PHILADELPHIA PA
19107-4965
US

V. Phone/Fax

Practice location:
  • Phone: 215-627-2143
  • Fax:
Mailing address:
  • Phone: 215-627-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP043383L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: