Healthcare Provider Details

I. General information

NPI: 1366489478
Provider Name (Legal Business Name): MARK GORDON REGNIER PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TRI PARK WAY
APPLETON WI
54914-1658
US

IV. Provider business mailing address

966 EVERGREEN LN
NEENAH WI
54956-4968
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-0070
  • Fax:
Mailing address:
  • Phone: 920-751-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number12035-040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number115369-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: