Healthcare Provider Details

I. General information

NPI: 1437222551
Provider Name (Legal Business Name): LISA ANN GRYTTENHOLM PHARMD.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE PHARMACY SERVICES F6-133, 1530
MADISON WI
53792-0001
US

IV. Provider business mailing address

600 HIGHLAND AVE PHARMACY SERVICES F6-133, 1530
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 608-890-8993
  • Fax:
Mailing address:
  • Phone: 608-890-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11939-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: