Healthcare Provider Details

I. General information

NPI: 1205434289
Provider Name (Legal Business Name): LISA CICHOCKI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 W MASON ST
GREEN BAY WI
54303-4711
US

IV. Provider business mailing address

4066 HUDSON HILL DR
HOBART WI
54155-8984
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-2330
  • Fax:
Mailing address:
  • Phone: 920-664-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17594-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: