Healthcare Provider Details

I. General information

NPI: 1639252562
Provider Name (Legal Business Name): ROBERTA A FREITAG R.PH., CGP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROBERTA AMUNDSON R.PH.

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750N THAYER RD
BIRCHWOOD WI
54817
US

IV. Provider business mailing address

2750N THAYER RD
BIRCHWOOD WI
54817
US

V. Phone/Fax

Practice location:
  • Phone: 715-354-3961
  • Fax:
Mailing address:
  • Phone: 715-354-3961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9734-040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number9734-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: