Healthcare Provider Details

I. General information

NPI: 1730464876
Provider Name (Legal Business Name): WARREN FOWLER PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 CARDINAL LN
GREEN BAY WI
54313-9569
US

IV. Provider business mailing address

623 VROMAN ST
GREEN BAY WI
54303-3637
US

V. Phone/Fax

Practice location:
  • Phone: 920-661-9355
  • Fax:
Mailing address:
  • Phone: 920-498-0318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9181
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: