Healthcare Provider Details

I. General information

NPI: 1124458468
Provider Name (Legal Business Name): JAY BUBRICK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2013
Last Update Date: 11/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 N PORT WASHINGTON RD
GLENDALE WI
53217-4913
US

IV. Provider business mailing address

4961 N WILDWOOD AVE
WHITEFISH BAY WI
53217-6015
US

V. Phone/Fax

Practice location:
  • Phone: 414-963-0811
  • Fax: 414-963-0830
Mailing address:
  • Phone: 414-964-1693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8332-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: