Healthcare Provider Details

I. General information

NPI: 1649520008
Provider Name (Legal Business Name): ATHLETE PHARMACIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 NAUTILUS DR APT 8
MADISON WI
53705-4358
US

IV. Provider business mailing address

211 NAUTILUS DR APT 8
MADISON WI
53705-4358
US

V. Phone/Fax

Practice location:
  • Phone: 414-207-0309
  • Fax:
Mailing address:
  • Phone: 414-207-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MARK V LORSON II
Title or Position: CEO
Credential: PHARMD, CGP
Phone: 414-207-0309