Healthcare Provider Details

I. General information

NPI: 1013002930
Provider Name (Legal Business Name): HOWARD JOHN MIZE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 S MAIN ST SUITE 101
DE FOREST WI
53532-1478
US

IV. Provider business mailing address

3745 SEQUIOA TRAIL
VERONA WI
53593
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-2712
  • Fax:
Mailing address:
  • Phone: 608-798-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8946-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: