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General NPI Number Information
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NPI Number | 1962788901
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Entity Type | Individual
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Provider Name | TAYLOR THOMAS WAIDELICH PHARM.D.
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Gender | Male
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Dates
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Enumeration Date | 10/21/2011
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Last Update Date | 10/21/2011
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Provider Practice Location Address
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Address Line | 875 E NAPIER AVE
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City | BENTON HARBOR
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State | MI
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Zip | 49022-6125
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Country | US
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Telephone | 269-983-3463
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Fax |
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Provider Business Mailing Address
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Address Line | 2940 PAGODA PATH
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City | STEVENSVILLE
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State | MI
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Zip | 49127-9327
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Country | US
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Telephone | 715-216-4292
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5302040666
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051.294936
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License Number State | IL
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