=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689795049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY NICOLE SOPPE PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 W KINNICKINNIC RIVER PKWY FAMILY PRACTICE CLINIC ANTICOAGULATION CLINIC
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215-3669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-649-7810
-----------------------------------------------------
Fax | 414-649-5437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 W OKLAHOMA AVE OUTPATIENT PHARMACY
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-649-6063
-----------------------------------------------------
Fax | 414-649-5367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 13742-040
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------