Healthcare Provider Details

I. General information

NPI: 1902129828
Provider Name (Legal Business Name): CHERYL ANN MERTENS BSPHARM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 S MAIN ST
LUCK WI
54853
US

IV. Provider business mailing address

PO BOX 1
NEW RICHMOND WI
54017-0001
US

V. Phone/Fax

Practice location:
  • Phone: 715-472-2122
  • Fax: 715-472-4423
Mailing address:
  • Phone: 715-246-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11179
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number114480
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: