MEDICARE: RAYMOND M LANGE PHARMD

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	15618-40	WI

General Provider Information

NPI Number	:	1548651052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND M LANGE PHARMD

Provider Business Mailing Address
First Line	:	1010 N ROCHESTER ST
Second Line	:
City	:	MUKWONAGO
State	:	WI
Zip	:	53149-8738
Country	:	US
Telephone Number	:	262-363-1680
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 N ROCHESTER ST
Second Line	:
City	:	MUKWONAGO
State	:	WI
Zip	:	53149-8738
Country	:	US
Telephone Number	:	262-363-1680
Fax Number	:

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

Provider Enumeration Date	:	02/05/2015
Last Update Date	:	02/05/2015

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