Basic Information
| Provider Information | |||||||||
| NPI: | 1003120403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENKE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 698 YELLOWSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | CODY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824149322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075276221 | ||||||||
| FaxNumber: | 3075276667 | ||||||||
| Practice Location | |||||||||
| Address1: | 698 YELLOWSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | CODY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824149322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075276221 | ||||||||
| FaxNumber: | 3075276667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 3211 | WY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.