MEDICARE: BRENDA DIANNE STRAWN R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	10194040	WI

General Provider Information

NPI Number	:	1477750420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA DIANNE STRAWN R.PH.

Provider Business Mailing Address
First Line	:	4019 N RUDELLA RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-2794
Country	:	US
Telephone Number	:	262-242-1922
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 WASHINGTON ST
Second Line	:
City	:	TWO RIVERS
State	:	WI
Zip	:	54241-3045
Country	:	US
Telephone Number	:	920-794-1225
Fax Number	:	920-794-7091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	07/08/2007

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