Healthcare Provider Details

I. General information

NPI: 1740625862
Provider Name (Legal Business Name): CYNTHIA EILEEN LIEBAU RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 E WASHINGTON AVE
MADISON WI
53704-3648
US

IV. Provider business mailing address

3801 E WASHINGTON AVE
MADISON WI
53704-3648
US

V. Phone/Fax

Practice location:
  • Phone: 608-244-4991
  • Fax:
Mailing address:
  • Phone: 608-244-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11213-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: