Provider Demographics
NPI:1538496914
Name:WOLFORD, BRENT (RPH)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WOLFORD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-1924
Mailing Address - Country:US
Mailing Address - Phone:812-349-1392
Mailing Address - Fax:812-349-1393
Practice Address - Street 1:500 S LIBERTY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-1924
Practice Address - Country:US
Practice Address - Phone:812-349-1392
Practice Address - Fax:812-349-1393
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-3023183500000X
IN26020479A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist