Provider Demographics
NPI:1962788901
Name:WAIDELICH, TAYLOR THOMAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:THOMAS
Last Name:WAIDELICH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 PAGODA PATH
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9327
Mailing Address - Country:US
Mailing Address - Phone:715-216-4292
Mailing Address - Fax:
Practice Address - Street 1:875 E NAPIER AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-6125
Practice Address - Country:US
Practice Address - Phone:269-983-3463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040666183500000X
IL051.294936183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist