Healthcare Provider Details

I. General information

NPI: 1740196468
Provider Name (Legal Business Name): MONICA MICOLICZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15650 W GREENFIELD AVE
BROOKFIELD WI
53005-6905
US

IV. Provider business mailing address

500 S 76TH ST
MILWAUKEE WI
53214-1548
US

V. Phone/Fax

Practice location:
  • Phone: 262-786-3692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23634
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: