Healthcare Provider Details

I. General information

NPI: 1639777089
Provider Name (Legal Business Name): JEREMY HAFIZ HUSAIN I PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 N MUTUAL WAY
APPLETON WI
54913-8415
US

IV. Provider business mailing address

1523 N DURKEE ST
APPLETON WI
54911-3711
US

V. Phone/Fax

Practice location:
  • Phone: 920-954-6400
  • Fax:
Mailing address:
  • Phone: 608-921-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17936-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: