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General NPI Number Information
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NPI Number | 1649520008
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Entity Type | Organization
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Legal Business Name | ATHLETE PHARMACIST LLC
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Dates
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Enumeration Date | 09/13/2012
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 211 NAUTILUS DR APT 8
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City | MADISON
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State | WI
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Zip | 53705-4358
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Country | US
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Telephone | 414-207-0309
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Fax |
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Provider Business Mailing Address
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Address Line | 211 NAUTILUS DR APT 8
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City | MADISON
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State | WI
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Zip | 53705-4358
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Country | US
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Telephone | 414-207-0309
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. MARK V LORSON II
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Credential | PHARMD, CGP
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Telephone | 414-207-0309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP0905X
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Taxonomy Name | State or Local Public Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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