Healthcare Provider Details

I. General information

NPI: 1285949214
Provider Name (Legal Business Name): BRIAN T WOJCZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2010
Last Update Date: 08/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 SUMMIT AVE
OCONOMOWOC WI
53066-4618
US

IV. Provider business mailing address

1450 SUMMIT AVE
OCONOMOWOC WI
53066-4618
US

V. Phone/Fax

Practice location:
  • Phone: 262-567-9254
  • Fax: 262-567-5293
Mailing address:
  • Phone: 262-567-9254
  • Fax: 262-567-5293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14867-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: