MEDICARE: LANCE BUTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	14743-40	WI

General Provider Information

NPI Number	:	1174122386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE BUTH

Provider Business Mailing Address
First Line	:	1033 NORFIELD RD
Second Line	:
City	:	SUAMICO
State	:	WI
Zip	:	54173-8529
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1244 E GREEN BAY ST
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166-2208
Country	:	US
Telephone Number	:	715-524-5983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2020
Last Update Date	:	10/19/2020

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Directions to “ LANCE BUTH ” Practice Location

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