Healthcare Provider Details

I. General information

NPI: 1699126920
Provider Name (Legal Business Name): COURTNEY MARIE PUTZ PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 E HILL PKWY APT 109
MADISON WI
53718-3310
US

IV. Provider business mailing address

970 BOLDEN AVE
SPARTA WI
54656-2490
US

V. Phone/Fax

Practice location:
  • Phone: 920-948-7743
  • Fax:
Mailing address:
  • Phone: 920-948-7743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18385-40
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number18385-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: