Healthcare Provider Details

I. General information

NPI: 1063423200
Provider Name (Legal Business Name): JONATHAN WILLIAM STROM RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 SOUTH WEBSTER AVE
GREEN BAY WI
54307-3400
US

IV. Provider business mailing address

2987 FLEETWOOD DR
GREEN BAY WI
54313
US

V. Phone/Fax

Practice location:
  • Phone: 920-431-5696
  • Fax: 920-431-5677
Mailing address:
  • Phone: 920-431-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12561040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: