Healthcare Provider Details

I. General information

NPI: 1881130169
Provider Name (Legal Business Name): MICHELLE MAYNARD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W. WISCONSIN AVE FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN
MILWAUKEE WI
53226
US

IV. Provider business mailing address

9200 W. WISCONSIN AVE FROEDTERT & THE MEDICAL COLLEGE OF WISCONSIN
MILWAUKEE WI
53226
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-8710
  • Fax:
Mailing address:
  • Phone: 414-805-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number13424
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: