Healthcare Provider Details

I. General information

NPI: 1205843646
Provider Name (Legal Business Name): LISA KOSTECKI RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 02/20/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MAIN ST
CROSS PLAINS WI
53528-9473
US

IV. Provider business mailing address

PO BOX 215
CROSS PLAINS WI
53528-0215
US

V. Phone/Fax

Practice location:
  • Phone: 608-798-3031
  • Fax: 608-798-3932
Mailing address:
  • Phone: 608-798-3031
  • Fax: 608-798-3932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10362-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: