Provider Demographics
NPI:1316350887
Name:WIECZOREK, JEFFREY JOHN (BS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:WIECZOREK
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9416 WILDWOOD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9430
Mailing Address - Country:US
Mailing Address - Phone:734-449-8706
Mailing Address - Fax:734-449-8706
Practice Address - Street 1:9416 WILDWOOD LAKE DR
Practice Address - Street 2:
Practice Address - City:WHITMORE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48189-9430
Practice Address - Country:US
Practice Address - Phone:734-449-8706
Practice Address - Fax:734-449-8706
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020321201835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302032120Medicaid