Provider Demographics
NPI:1285928150
Name:WHEATLEY, THERESA ANNE (RPH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6839 S WESTNEDGE AVE
Mailing Address - Street 2:PHARMACY T0604
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3582
Mailing Address - Country:US
Mailing Address - Phone:269-327-9646
Mailing Address - Fax:
Practice Address - Street 1:6839 S WESTNEDGE AVE
Practice Address - Street 2:PHARMACY T0604
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3582
Practice Address - Country:US
Practice Address - Phone:269-327-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist