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NPI Code Detail

MEDICARE: THOMAS J WICKSTROM RPH

MEDICARE: THOMAS J WICKSTROM RPH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist5302032441MI

General Provider Information

NPI Number : 1700167475
Entity Type Code : Individual
Provider Name (Legal Business Name) : THOMAS J WICKSTROM RPH
Provider Business Mailing Address
First Line : 3610 PLAINFIELD AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49525-2402
Country : US
Telephone Number : 616-365-1221
Fax Number : 616-365-9996
Provider Business Practice Location Address
First Line : 3610 PLAINFIELD AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49525-2402
Country : US
Telephone Number : 616-365-1221
Fax Number : 616-365-9996
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/07/2011
Last Update Date : 09/07/2011

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Directions to “ THOMAS J WICKSTROM RPH” Practice Location

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