Provider Demographics
NPI:1528073145
Name:WAKEFIELD PHARMACY ENTERPRISES LTD
Entity type:Organization
Organization Name:WAKEFIELD PHARMACY ENTERPRISES LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-229-5966
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49968-0171
Mailing Address - Country:US
Mailing Address - Phone:906-229-5966
Mailing Address - Fax:
Practice Address - Street 1:408 SUNDAY LAKE ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MI
Practice Address - Zip Code:49968-1338
Practice Address - Country:US
Practice Address - Phone:906-229-5966
Practice Address - Fax:906-229-5707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301008317333600000X, 332B00000X
3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2327953OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI871923680Medicaid
MI5674740001Medicare NSC