Healthcare Provider Details

I. General information

NPI: 1275605685
Provider Name (Legal Business Name): JACK L PATZER BS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 W NATIONAL AVE
NEW BERLIN WI
53151-9521
US

IV. Provider business mailing address

1920 N FARWELL AVE UNIT #210
MILWAUKEE WI
53202-1571
US

V. Phone/Fax

Practice location:
  • Phone: 262-797-4610
  • Fax: 262-797-4615
Mailing address:
  • Phone: 414-520-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number8105-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: