Provider Demographics
NPI:1083437099
Name:WELLS, MICHAEL JAMES (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:WELLS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 N BREENS BAY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-8724
Mailing Address - Country:US
Mailing Address - Phone:262-434-0041
Mailing Address - Fax:
Practice Address - Street 1:1173 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1672
Practice Address - Country:US
Practice Address - Phone:262-473-2225
Practice Address - Fax:262-473-2226
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11690-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist