Healthcare Provider Details

I. General information

NPI: 1275017584
Provider Name (Legal Business Name): KEVIN STARAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 W BURLEIGH ST
WAUWATOSA WI
53222-3211
US

IV. Provider business mailing address

11111 W BURLEIGH ST
WAUWATOSA WI
53222-3211
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-0910
  • Fax:
Mailing address:
  • Phone: 414-290-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19344
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: