Provider Demographics
NPI:1477435949
Name:WICKSTROM, HAILEY
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59260 DEXTROM RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-8842
Mailing Address - Country:US
Mailing Address - Phone:906-369-3402
Mailing Address - Fax:
Practice Address - Street 1:101 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1803
Practice Address - Country:US
Practice Address - Phone:231-796-7621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302417713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist