Healthcare Provider Details

I. General information

NPI: 1407481922
Provider Name (Legal Business Name): SUSAN KAYE OGNACEVIC RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 W GREENFIELD AVE
WEST ALLIS WI
53214-2730
US

IV. Provider business mailing address

404 N 49TH ST
MILWAUKEE WI
53208-3628
US

V. Phone/Fax

Practice location:
  • Phone: 414-456-9228
  • Fax: 414-456-0882
Mailing address:
  • Phone: 414-430-1218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10471-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: