Healthcare Provider Details

I. General information

NPI: 1972416717
Provider Name (Legal Business Name): LARA REBECCA AWE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD
MEQUON WI
53097-2416
US

IV. Provider business mailing address

1164 W PORTVIEW DR
PORT WASHINGTON WI
53074-2320
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7341
  • Fax:
Mailing address:
  • Phone: 262-355-4223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17713-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: