Healthcare Provider Details

I. General information

NPI: 1720162068
Provider Name (Legal Business Name): THOMAS A CHRISTIANSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E COOK ST
PORTAGE WI
53901-2204
US

IV. Provider business mailing address

117 E COOK ST
PORTAGE WI
53901-2204
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-3737
  • Fax: 608-742-0216
Mailing address:
  • Phone: 608-742-3737
  • Fax: 608-742-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6336
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9631-040
License Number StateWI

VIII. Authorized Official

Name: THOMAS CHRISTIANSON
Title or Position: OWNER/PHARMACIST
Credential: R.PH.
Phone: 608-742-3737